skip to content

Screening Form

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

    * Indicates a required field.

  • Step 2 of 3 - Medical Information
    1. Is this person allergic to doxycycline or other tetracycline ("cycline") drugs?
    2. Is this person allergic to ciprofloxacin or other quinolone ("floxacin") drugs?
    3. Is this person allergic to amoxicillin, penicillin or other ("cillin") drugs?
    4. Is this person currently taking any prescription drugs (excluding birth control)?

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

    4a. Is this person taking tizanidine (Zanaflex), theophylline, or duloxetine?
    4b. Is this person taking isotretinoin, phenobarbital, carbamazepine, primidone, rifampin, phenytoin, or fosphenytoin?
    5. Has a doctor told this person they have chronic kidney disease/kidney failure?
    6. Has a doctor told this person they have seizures/epilepsy, myasthenia gravis, prolonged QT syndrome, or an aortic aneurysm or dissection?
    7. Is this person pregnant or breastfeeding?
    8. Is this person 65 years old or older?
    9. Is this person 17 years old or younger?

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

    FOR CHILDREN ONLY

  • Step 3 of 3 - Results

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