current Please list any medical conditions: current Please list any medications: Please Circle your answer for the below questions: Are there any medications to which you have had an allergic reaction? Yes No If yes, Please list medications: If yes, Please list type of reaction: Have you ever had an allergic reaction to eggs, mercury (thimerosal), bee stings, formaldehyde, or sunlight? Yes No Have you ever had a seizure, brain or nerve problem? Yes No Are you currently being treated for leukemia, lymphoma, cancer, or any other type of malignant disease? Yes No Do you have a known history of an incompetent immune system? Yes No Do you have a history of anemia or any other known blood disorder? Yes No Have you had any blood, blood products or IG in the past year? Yes No Do you have a history of Guillain-Barre Syndrome? Yes No Do you have a cochlear implant? Yes No Are you currently taking any forms of steroids? Yes No Do you have any spleen problems or have had a splenectomy? Yes No Date of Last Menstrual Period: N/A What type of birth control do you use? Are you pregnant? Yes No Have you been on any antibiotic in the last 2 weeks? Yes No If yes, Please List: Have you had any vaccinations in the past 4 weeks? Yes No If yes, Please List: Have you ever had a serious reaction to a vaccine? Yes No If yes, Please List: Thank you for choosing the FDOH Polk County Health Department for your travel vaccines. We look forward to helping you plan for a safe trip.
Please list any current medical conditions: Please list any current medications: Please Circle your answer for the below questions: Are there any medications to which you have had an allergic reaction? Yes No If yes, Please list medications: If yes, Please list type of reaction: Have you ever had an allergic reaction to eggs, mercury (thimerosal), bee stings, formaldehyde, or sunlight? Yes No Have you ever had a seizure, brain or nerve problem? Yes No Are you currently being treated for leukemia, lymphoma, cancer, or any other type of malignant disease? Yes No Do you have a known history of an incompetent immune system? Yes No Do you have a history of anemia or any other known blood disorder? Yes No Have you had any blood, blood products or IG in the past year? Yes No Do you have a history of Guillain-Barre Syndrome? Yes No Do you have a cochlear implant? Yes No Are you currently taking any forms of steroids? Yes No Do you have any spleen problems or have had a splenectomy? Yes No Date of Last Menstrual Period: N/A What type of birth control do you use? Are you pregnant? Yes No Have you been on any antibiotic in the last 2 weeks? Yes No If yes, Please List: Have you had any vaccinations in the past 4 weeks? Yes No If yes, Please List: Have you ever had a serious reaction to a vaccine? Yes No If yes, Please List: Thank you for choosing the FDOH Polk County Health Department for your travel vaccines. We look forward to helping you plan for a safe trip.