Vaccination Screening Questionnaire

1

Patient Name* This field is required.

First Name

Last Name

2

Patient Date of Birth* This field is required.

Date

3

Your name and relationship to the child* This field is required.

Jane Doe - Mother

4

Email

example@example.com

5

Phone Number* This field is required.

Area Code

Phone Number

6

Is your child sick today?* This field is required.

YESNO

7

Does your child have an allergy to medications, gelatin, eggs, yeast, or latex? * This field is required.

YESNO

8

If yes, what kind of reaction?
Did your child require epinephrine (epi-pen)? yes no

9

Has your child had a serious reaction to a vaccine before?* This field is required.

YESNO

10

Does your child have a long-term health problem/condition, such as kidney, lung, heart condition, asthma, blood disorder, absence of spleen, cochlear implant, spinal fluid leak, or metabolic disease such as diabetes?* This field is required.

YESNO

11

If yes, what is the health problem?

12

If your child is a baby, have you ever been told your child has intussusception?* This field is required.

YESNO

13

Has your child, sibling, or parent ever had a seizure? Does your child have any brain or nervous system problems?* This field is required.

YESNO

14

Does your child have an immune system problem, HIV/AIDS, leukemia, or cancer?* This field is required.

YESNO

15

Does your child live with someone who has an immune system problem?* This field is required.

YESNO

16

In the past three months has your child had any medications that affect the immune system, such as prednisone, other steroids, or anti-cancer drugs? * This field is required.

YESNO

17

Has your child had drugs that treat rheumatoid arthritis, psoriasis, Crohn’s Disease, or ulcerative colitis?* This field is required.

YESNO

18

Has your child had radiation therapy?* This field is required.

YESNO

19

In the past year has your child received a blood transfusion or transfusion of blood products? Has your child been given immune globulin or an antiviral drug?* This field is required.

YESNO

20

Is your child pregnant or could become pregnant in the next month?* This field is required.

YESNO

21

Has your child received a vaccine in the last month?* This field is required.

YESNO

22

If your child is between the ages of 2 years - 4 years, has a doctor said your child has wheezing or asthma in the last 12 months?* This field is required.

YESNO