Travel Counseling History

Travel Counseling History
[select name="Q1" value="male|female"] <-- Gender[conditional field="Q1" condition="(Q1).is('female')"]
[select value="no|YES"] <-- Pregnant
[select value="no|YES"] <-- Trying to become pregnant in next 3 months[/conditional]
[text] <-- Age
[textarea default="Past medical history notable for"]
[textarea default="Itinerary is"]
[select name="Q2" value="business|vacation|missionary|diving|backcountry|hiking|biking|climbing|health care delivery|other"] <-- Travel purpose [conditional field="Q2" condition="(Q2).is('other')"][text][/conditional]
Accommodations include:
[select value="no|YES"] <-- hotel/resort
[select value="no|YES"] <-- private home
[select value="no|YES"] <-- safari/camp
[select value="no|YES"] <-- hostel
[select name="Q3" value="no|YES"] <-- other [conditional field="Q3" condition="(Q3).is('YES')"][text][/conditional]
History of...
[select value="no|YES"] <-- fever in the past 48 hours
[select value="no|YES"] <-- candidal vaginitis
[select value="no|YES"] <-- frequent UTIs
[select value="no|YES"] <-- breast feeding
[select value="no|YES"] <-- oral contraceptive use currently
[select value="no|YES"] <-- HIV/AIDS
[select value="no|YES"] <-- other immune disorders
[select value="no|YES"] <-- leukemia
[select value="no|YES"] <-- transplantation
[select value="no|YES"] <-- cancer
[select value="no|YES"] <-- living or working closely with anyone with these disorders or anyone currently receiving chemotherapy
[select value="no|YES"] <-- blood clotting/bleeding disorder
[select value="no|YES"] <-- seizures
[select value="no|YES"] <-- psychiatric problems
[select value="no|YES"] <-- psoriasis
[select value="no|YES"] <-- abnormal heart rhythm
[select value="no|YES"] <-- tuberculosis exposure
[select value="no|YES"] <-- splenectomy
[select value="no|YES"] <-- ulcer
[select value="no|YES"] <-- indigestion
[select value="no|YES"] <-- diarrhea
[select value="no|YES"] <-- stomach surgery
[select value="no|YES"] <-- jaundice
[select value="no|YES"] <-- hepatitis
[select value="no|YES"] <-- hives or urticaria

Malaria prophylaxis history
[select value="no|YES"] <-- Reports having taken malaria chemoprophylaxis previously.

Adverse vaccine or injection reactions
[select value="no|YES"] <-- History of fainting from injections
[select value="no|YES"] <-- History of reactions to previous vaccines

Has received these in the last 8 months?
[select value="no|YES"] <-- immune globulin
[select value="no|YES"] <-- blood products

Has received these in the last 4 weeks?
[select value="no|YES"] <-- antibiotics

Motion sickness?
[select value="no|YES"] <-- Is prone to motion sickness