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Click ‘Get Form’ to open it in the editor.
Begin by filling out your travel history in the past 6 months. Provide details for both yourself and your partner in the designated fields.
Indicate whether you or your partner have experienced any symptoms such as fever, rash, joint pain, or red eyes within the last 6 months by selecting 'Yes' or 'No'.
Answer if either you or your partner has been infected with the Zika Virus in the last 6 months by marking 'Yes' or 'No'.
Review and circle 'Yes' or 'No' for travel to Zika risk areas as listed on the CDC website. Ensure you acknowledge this information.
Finally, confirm if there has been unprotected sexual contact with anyone who has had Zika exposure. Sign and date at the bottom of the form.

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