Head of Household POD Form (3 Questions)

POD Form - 3 Qs

Household Members

Is household member:

Pregnant, Breast Feeding, 8 years of age or under?

Does this person have a severe life-threatening allergy to/or has been told to avoid any of the following?

Doxycyline (Vibramycin), Minocylcine (Minocin), Tetracycline (Achromycin, Brodspec, EmTet, Sumycin, Tetracap, Panmycin), Other “-cycline” drugs

Does this person have a severe life-threatening allergy to/or has been told to avoid any of the following?

Ciprofloxacin (Cipro), Levofloxacin (Levaquin), Ofloxacin (Floxin), Moxifloxacin (Avelox), Other “-floxacin” drugs

Add or remove a household member:

Add Another Household Member Remove this Household Member