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Travel Medicine Questionnaire
To have a representative contact you about your foreign travel medical needs, please complete the fields below.
All fields are required unless indicated as optional.
"
*
" indicates required fields
Your Name:
*
First
Last
Sex:
*
Male
Female
Date of Birth:
*
MM slash DD slash YYYY
Your Phone Number:
*
Your Email Address:
*
Hidden
What Doctors Care center providing travel medicine treatment are you closest to?
*
Select
Midlands, South Carolina - Doctors Care Seven Oaks
Upstate, South Carolina - Doctors Care Simpsonville
Lowcountry, South Carolina - Doctors Care Northwoods
Date of Departure:
*
MM slash DD slash YYYY
Destination(s):
*
Please list all cities/countries.
What is the purpose of your trip?
*
Business
Pleasure
Other
Are you staying mostly in cities/tourist destinations?
*
Yes
No
Are you going to spend time in a rural area?
*
Yes
No
Unsure
Are you going to spend time above 5000 ft?
*
Yes
No
Unsure
Are you going to work in the foreign country?
*
Yes
No
Unsure
Are you currently being treated for any medical problems?
*
Yes
No
Have you had a significant medical problem in the past?
*
Yes
No
Could you be pregnant?
*
Yes
No
Unsure
Are you allergic to eggs or chicken products?
*
Yes
No
Unsure
Have you had any hypersensitivity or reaction to vaccinations?
*
Yes
No
Unsure
Have you had Guillain-Barre Syndrome?
*
Yes
No
Have you had all of your childhood vaccinations?
*
Yes
No
Unsure
Have you had tetanus/diphtheria vaccination in the last 10 years?
*
Yes
No
Unsure
Have you had measles vaccination (2 shots)?
*
Yes
No
Unsure
Have you had polio vaccination as an adult?
*
Yes
No
Unsure
Have you had hepatitis A vaccination (2 shots)?
*
Yes
No
Unsure
Have you had hepatitis B vaccination (3 shots)?
*
Yes
No
Unsure
Have you had meningitis vaccination in the past 3 years?
*
Yes
No
Unsure
Have you had typhoid vaccination in the past 2 years (if injected), or in the past 5 years (if oral)?
*
Yes
No
Unsure
Have you had yellow fever vaccination in the past 10 years?
*
Yes
No
Unsure
Have you had Japanese encephalitis vaccination in the past 2 years?
*
Yes
No
Unsure
Do you have any current or previous significant medical conditions?
*
Yes
No
List any current or previous significant medical conditions:
Are you currently taking any medications (prescription or over-the-counter)?
*
Yes
No
List all medications currently being taken:
Please include all prescription and over-the-counter medications being taken currently.
Do you have any allergies?
*
Yes
No
List allergies:
Additional comments: (optional)
Comments
This field is for validation purposes and should be left unchanged.
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Services
Urgent Care
Family and Primary Care
Virtual Urgent Care
COVID-19 Testing & Care
Flu Vaccines, Testing & Care
Sports and Camp Physicals
Employer Health Services
Travel Medicine
Physical Therapy
FAQs
Virtual Visit
Locations
Pricing
Insurance
Self-Pay Pricing
Patient Portal
Employers
Careers