You can always press Enter⏎ to continue
Vaccination Screening Questionnaire
Vaccination Screening Questionnaire
Hi there, please complete this form so we can safely give your child vaccinations. If you have more than one child, please complete a form for each child.
22Questions
Vaccination Screening Questionnaire
  • 1
    Press
    Enter
  • 2
    -
    Pick a Date
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Press
    Enter
  • 8

    If yes, what kind of reaction?            
    Did your child require epinephrine (epi-pen)?               

    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Press
    Enter
  • 11

    If yes, what is the health problem?       

    Press
    Enter
  • 12
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Press
    Enter
  • 18
    Press
    Enter
  • 19
    Press
    Enter
  • 20
    Press
    Enter
  • 21
    Press
    Enter
  • 22
    Press
    Enter
  • Should be Empty:
hipaa badge
Question Label
1 of 22See AllGo Back
close