MVP Mutual Vaccine Administration Record Questionnaire

Vaccine Administration Record Mt. Vernon Pharmacy at Fallsway 421 Baltimore, MD 21201-5311

Phone: (410)539-8030 Fax: (410)539-8115

Name*

First NameLast Name

Address*

Address

Street Address Line 2

CityState

Zip

WHICH GENDER IS LISTED WITH YOUR INSURANCE COMPANY?*

MALEFEMALE

Date of Birth:*

Date

Phone:*

Allergies:

RACE

Primary Care Physician:

Mother's Maiden Name:*

Patient's Email:

example@example.com

WHICH VACCINES WOULD YOU LIKE TO RECEIVE TODAY?*

WHICH ARM DO YOU WANT US TO INJECT?

LEFTRIGHT

ARE YOU SICK TODAY?

YESNO

Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?

YESNO

Have you ever had a serious reaction after receiving a vaccination?

YESNO

Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?

YesNo

Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes) anemia or other blood disorder?

YesNo

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, herpes, or cold sores?

YesNo

In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?

YesNo

Have you had a seizure or a brain or other nervous system problem or Guillain Barre?

YesNo

During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug (including acyclovir famciclovir, valacyclovir)?

YesNo

For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNo

Have you received any vaccinations or TB skin test in the past 4 weeks?

YesNo

Do you have a history of fainting, particularly with vaccines?

YesNo

For Tdap and adult Td: Do you have a cut, injury, puncture or open wound that prompted you to get a tetanus shot?

YesNo

For Zoster: Have you had a past reaction to gelatin or triple antibiotic ointment?

YesNo

Consent: I have read or have read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I certify that I am at least 18 years old and hereby give my consent to the pharmacist to administer the vaccine(s). If under 18 years old, signature by parent or guardian is years required. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless the pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Signature*

Date*

Date