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New Hanover County Health & Human Services

travel_clinic_info@nhcgov.com

1650 Greenfield Street Wilmington, NC 28401

910-798-3500

TRAVEL CLINIC SURVEY

What is your date of birth?

What date will you be leaving the United States?

What date will you be returning to the United States?

Your travel will primarily be:

Please identify your travel accommodations. Check all that apply:

Are you allergic to any medications?

Are you pregnant or planning to become pregnant?

Are you breastfeeding?

Have you had any severe reactions to past vaccines?

Do you have, or have you had a history with, any of the following medical conditions?

Do you have an allergy/sensitivity to any of the following? Check all that apply:

Are you immunosuppressed due to any of the following? Check all that apply:

Are you taking sulfonamides or antibiotics?

Are you currently experiencing an acute gastrointestinal illness?