Screening Form

Complete and print one form per person.
Step 1 of 3 - Demographic Information

* Indicates a required field.

Full Name *

Address *

City *

State *

Zip / Postal Code *

Phone
Step 2 of 3 - Medical Information

1. Is this person allergic to doxycycline or other tetracycline ("cycline") drugs?
Yes No

2. Is this person allergic to ciprofloxacin or other quinolone ("floxacin") drugs?
Yes No

3. Is this person allergic to amoxicillin, penicillin or other ("cillin") drugs?
Yes No

4. Is this person currently taking any prescription drugs (excluding birth control)?
Yes No

If yes to question 4, answer 4a and 4b:

4a. Is this person taking tizanidine (Zanaflex), theophylline, or duloxetine?
Yes No

4b. Is this person taking isotretinoin, phenobarbital, carbamazepine, primidone, rifampin, phenytoin, or fosphenytoin?
Yes No

5. Has a doctor told this person they have chronic kidney disease/kidney failure?
Yes No

6. Has a doctor told this person they have seizures/epilepsy, myasthenia gravis, prolonged QT syndrome, or an aortic aneurysm or dissection?
Yes No

7. Is this person pregnant or breastfeeding?
Yes No

8. Is this person 65 years old or older?
Yes No

9. Is this person 17 years old or younger?
Yes No

If yes to question 9, please provide child's age and weight below:

FOR CHILDREN ONLY

Age (select one):

Weight:
Step 3 of 3 - Results

If information is correct, print this page by clicking the button below and bring it to the POD site

Screening Form Instructions