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Allergies
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Have you ever visited outside of United States?
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Purpose of Travel
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Countries and cities are visiting
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Which one describes purpose of your travel the most?
Visiting only major cities
Staying in hotel all the time
Visiting rural areas
Travelling to high altitude >7000ft above see levels
Having contact with new sexual partners
HAVE YOU EVER HAD ANY OF THESE VACCINES BEFORE?
Hepatitis A
Yes
No
Not Sure
Hepatitis B
Yes
No
Not Sure
Flu Vaccine
Yes
No
Not Sure
Meningitis Vaccine
Yes
No
Not Sure
Measles, Mumps, and Rubella Vaccine
Yes
No
Not Sure
Tetanus-Diphteria-Pertusis
Yes
No
Not Sure
Pneumonococal
Yes
No
Not Sure
Thyphoid
Yes
No
Not Sure
Rabies
Yes
No
Not Sure
Japanese Encephalitis
Yes
No
Not Sure
Shingles
Yes
No
Not Sure
Please list all of your current medications
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