Name * First Name Last Name Email * Age Sex * Female Male Where are you going? Please list each country/city below. What modes of transportation do you anticipate using? Car Plane Train/Subway Boat/Cruise ship Bus Do you fit into any of the following categories? * Humanitarian aid or health care worker Cruise ship passenger Long-term traveler or expatriate Last-minute traveler None of these apply Does your itinerary include any of the following? * Returning home to visit family or friends Study abroad/student travel Traveling to a mass gathering My itinerary does not include any of these Do you have any of the following medical conditions? * Severe egg allergy (i.e. hives or swelling of the lips or tongue or difficulty breathing or collapsing after eating eggs) Thymus disease or history of thymectomy Neuropsychiatric condition Seizure disorder Heart conduction abnormality Psoriasis Severe renal impairment Chronic liver disease Pregnant Planning pregnancy in the next three months Breastfeeding Are you allergic to any medications? If so, which ones? Please list the chronic medical conditions for which you are being treated. List the medications (including supplements & herbs) that you take regularly. Please share two concerns you would like addressed during our meeting. * How did you hear about us? Thank you!
