Med Form Do you have a history of nausea or vomiting while traveling?
Have you ever been diagnosed with the following: torsade's de pointes, long QT syndrome, cardiac arrhythmias, a low potassium level , or a low magnesium level, or a family history of sudden cardiac death?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Have you ever been diagnosed with a dystonic reaction (involuntary contractions of muscles within minutes or hours of taking a medication)?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
How many hours of medicine coverage do you think you need per dose?
Do you have a history of: systemic macrocytosis, psychosis, wide angle glaucoma, closed angle glaucoma, liver disease, kidney dysfunction, urinary retention, preeclampsia, seizures?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Are you planning to have an MRI while using this medication?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Are you traveling above 2500 meters/8000 feet?
How many days will it take to get to the altitude?
Do you have a history of AMI (acute mountain illness)?
Do you have a history of sickle cell trait or disease?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Do you have a history of the following medical conditions: obesity, cystic fibrosis, poorly controlled chronic conditions (including asthma, diabetes, seizure disorder, hypertension, arrhythmia), cardiovascular disease, pulmonary hypertension, COPD, severe scoliosis, NMD, OSA, or COPD?
You are at higher risk of high altitude illness. Does your primary care provider know you engage in high altitude activities? If not, please get clearance from your primary provider PRIOR to planning your travel.
Have you ever had the following medical conditions: high altitude pulmonary edema (HAPE), high altitude cerebral edema (HACE)
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Do you have a sulfa allergy?
Have you taken acetazolamide/Diamox in the past, and if so have you had any reaction to it?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Do you have an allergy or intolerance to azithromycin?
Have you ever had traveler's diarrhea?
Do you currently have diarrhea?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Do you have a history of inflammatory bowel disease?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Have you ever been hospitalized with a C. diff infection?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Do you have any of the following conditions: chronic kidney disease, myasthenia gravis, G6PD deficiency, or are you over the age of 65?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Do you have any history of an arrhythmia, torsade's de pointes, or long QT syndrome?
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Do you have a suppressed immune system (chemotherapy, HIV/AIDS, on chronic steroid or immunosuppressant medicine, etc.)
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
Information about yourself
Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.
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