Travel Counseling History
<-- Gender
<-- Age


<-- Travel purpose
Accommodations include:
<-- hotel/resort
<-- private home
<-- safari/camp
<-- hostel
<-- other
History of...
<-- fever in the past 48 hours
<-- candidal vaginitis
<-- frequent UTIs
<-- breast feeding
<-- oral contraceptive use currently
<-- HIV/AIDS
<-- other immune disorders
<-- leukemia
<-- transplantation
<-- cancer
<-- living or working closely with anyone with these disorders or anyone currently receiving chemotherapy
<-- blood clotting/bleeding disorder
<-- seizures
<-- psychiatric problems
<-- psoriasis
<-- abnormal heart rhythm
<-- tuberculosis exposure
<-- splenectomy
<-- ulcer
<-- indigestion
<-- diarrhea
<-- stomach surgery
<-- jaundice
<-- hepatitis
<-- hives or urticaria

Malaria prophylaxis history
<-- Reports having taken malaria chemoprophylaxis previously.

Adverse vaccine or injection reactions
<-- History of fainting from injections
<-- History of reactions to previous vaccines

Has received these in the last 8 months?
<-- immune globulin
<-- blood products

Has received these in the last 4 weeks?
<-- antibiotics

Motion sickness?
<-- Is prone to motion sickness

Result - Copy and paste this output: