Note: This form should only be used for international travel

1. Name(*)
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2. Sex(*)
   Male Female Invalid Input
3. Birthdate
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4. Phone(*)
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5. Email(*)
   Invalid Input
6. Your Destination (countries/cities)
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7. Dates Of Trip
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8. Purpose of your trip
   Business Pleasure other Invalid Input
9. Are you currently treated for any medical problems
   Yes No Invalid Input
10. Have you had a significant medical problem in the past
    Yes No Invalid Input
11. Could you be pregnant
    Yes No Invalid Input
12. Are you staying mostly in cities / tourist destinations
    Yes No Invalid Input
13. Are you going to spend time in a rural area
    Yes No Unsure Invalid Input
14. Are you going to spend time above 5000 ft
    Yes No Unsure Invalid Input
15. Are you going to work in the foreign country
    Yes No Invalid Input
16. Are you allergic to eggs or chicken products
    Yes No Unsure Invalid Input
17. Have you had any hypersensitivity or reaction to vaccinations
    Yes No Unsure Invalid Input
18. Have you had Guillain-Barre Syndrome
    Yes No Invalid Input
19. Did you have all of your childhood vaccinations
    Yes No Unsure Invalid Input
20. Did you have tetanus/diphtheria vaccination in the last 10 years
    Yes No Invalid Input
21. Did you have polio vaccination as an adult
    Yes No Invalid Input
22. Did you have hepatitis A vaccination (2 shots)
    Yes No Unsure Invalid Input
23. Did you have hepatitis B vaccination (3 shots)
    Yes No Unsure Invalid Input
24. Did you have meningitis vaccination in the past 3 years
    Yes No Invalid Input
25. Did you have typhoid vaccination in the past 2 years (if injected), or in the past 5 years (if oral)
    Yes No Unsure Invalid Input
26. Did you have yellow fever vaccination in the past 10 years
    Yes No Unsure Invalid Input
27. Did you have Japanese encephalitis vaccination in the past 2 years
    Yes No Invalid Input
28. List current or previous significant medical conditions
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29. List current medications
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30. List allergies
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31. Comments
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32. Submit