Houston Methodist Wellness Services Travel Medicine Questionnaire

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Business Information
Itinerary
Flight Itinerary, Including Airport Stopovers
Medical History
Do You Have a History of Any of the Following?
Has Your Spleen Been Removed?


Do You Have a Condition That is Now Stable but Which May Recur During Travel?


Women: Are You Now Pregnant or Considering Becoming Pregnant?

Dates of Past Immunizations (mm/dd/yyyy)
Have You Ever Had the Measles (rubella)?


Have You Ever Fainted or Had an Adverse Reaction to a Vaccine?


May We Contact You at the E-mail Address Above?


I Verify That The Above Information Is Correct
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