Wandr Health Intake

1
Thank you for ordering travel medications with Wandr!* This field is required.The following questionnaire collects important information to assist your physician in prescribing your medications.
2
Where are you traveling?* This field is required.Please select one or more destinations.
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
3
Departure Date* This field is required.Select the departure date for your trip. For multiple countries, this is the date you depart from the United States.
Departure
Month
Day
Year
4
Return Date* This field is required.Select the return date for your trip. For multiple countries, this is the date you return to the United States.
Return
Month
Day
Year
5
Are you traveling above 8,000 feet in elevation or seeking therapy for altitude sickness?* This field is required.
YESNO
6
How many days will it take to ascend to your highest altitude?* This field is required.Altitude sickness prophylaxis is prescribed based on the number of days you will be climbing from your lowest to highest altitude, so please be precise!
7
Are you traveling to a malaria prone area and are you requesting medications for malaria prophylaxis?* This field is required.
YESNO
8
How many days will you be traveling in this area?* This field is required.Malaria prophylaxis is prescribed based on the number of days you are traveling within an endemic area, so please be precise!
9
What is your name?* This field is required.
First Name
Last Name
10
What is your date of birth?* This field is required.
Birthday
Month
Day
Year
11
Current Date
Date
Month
Day
Year
12
Age
13
Email* This field is required.By providing your email, you consent to receiving email correspondence from Wandr.
Please use only your order email
14
Phone Number* This field is required.Enter a phone number so your physician or our support team can reach you for questions.
Please enter a valid phone number.
15
ID Upload* This field is required.Per state guidelines, please upload a photo ID so we can confirm your identity.
Drag and drop files here
Select files to upload
Max. file size: 3.0MB
Please upload only JPEG, JPG, or PNG files
Cancelof
16
Do you have any medical conditions?* This field is required.
YESNO
17
Please identify all your current medical conditions:* This field is required.
18
Are you currently taking any medications?* This field is required.
YESNO
19
Please list all your current medications including dosages:* This field is required.
20
Do you have any allergies?* This field is required.
YESNO
21
Please list all of your known allergies:* This field is required.
22
Please indicate if you have allergies to any of the medications listed:* This field is required.
Cephalosporins (example: Keflex, cephalexin)
Penicillins (example: Amoxicillin)
Fluoroquinolones (example: Ciprofloxacin, Levofloxacin)
Macrolides (example: Azithromycin (Z-packs), erythromycin)
Sulfonamides (example: Sulfa, Bactrim)
Tetracyclines (example: Doxycycline)
Clindamycin
None of the above
Other
23
What was your sex assigned at birth?* This field is required.
Male
Female
24
Are you currently pregnant, breastfeeding or planning to become pregnant?* This field is required.
YESNO
25
Consent (Pregnancy)* This field is required.I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus. I understand that I should not take any of the medications within this kit if I’m attempting to become pregnant, am pregnant, or breastfeeding. By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
I have read and understand the above information, I understand the risks and wish to proceed
I have read the information and do NOT wish to proceed
26
What is your height in feet and inches?* This field is required.
ex. 5' 7"
27
What is your weight in pounds?* This field is required.
Use only the number in pounds (lbs)
28
Have you had a general health checkup in the last 2 years?* This field is required.
YESNO
29
Do you have a primary care physician?* This field is required.
YESNO
30
Have you ever been diagnosed with advanced kidney disease (CKD stage 4 or 5) or liver cirrhosis?* This field is required.
YESNO
31
Consent (Truthfulness)* This field is required.You are being provided with a medication kit that may include antibiotics or other symptomatic treatment medications for emergency use only. These medications are intended for situations where immediate medical care may not be accessible or available. By accepting this medication pack, you acknowledge and agree to the following: Intended Use: The medications provided are for emergency use in situations where: 1) You are traveling to areas where standard healthcare may not be accessible. 2) There is a disruption in the healthcare supply chain, limiting access to necessary treatment. 3) You are unable to obtain timely healthcare in urgent or emergency situations. 4) You have consulted your medical provider and received guidance on appropriate use. Not for Routine or Preventive Use: These medications are not intended for routine, preventive, or self-diagnosed treatment without medical consultation, except in situations where medical care is impossible to obtain. Most Infections Are Viral: You understand that most common infections are viral in nature and will resolve on their own without the use of antibiotics. Antibiotics are ineffective against viral infections and should not be used unless there is a clear indication of a bacterial infection. Risks of Inappropriate Use: Inappropriate use of antibiotics or other medications can result in: 1) Treatment failure or delayed recovery 2) Adverse side effects or allergic reactions 3) The development of antibiotic resistance, making future infections harder to treat You agree to follow all written instructions provided with your medication pack and seek medical advice when possible before using any medication. Proper Use and Responsibility: You agree to use the medications only as directed and only in emergency situations as described above Storage and Safety: You agree to store the medication pack securely and out of reach of children or unauthorized persons You will dispose of unused or expired medications safely, following FDA guidelines or through a drug take-back program Acknowledgment: 1) You understand that the purpose of this medication pack is to provide a backup option in emergency or extraordinary circumstances only 2) You confirm that you understand the risks of improper antibiotic use, including antibiotic resistance 3) You accept full responsibility for the proper and safe use of these medications in accordance with this consent By accepting this medication pack, you confirm that you have read, understood, and agree to the conditions outlined above.
I have read the above information and I do consent and wish to move forward
I have read the above information and I do not wish to continue
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