Dimino, M.D. M. Victoria Lopez-Beecham, M.D. Luis P. Leyva, Jr., M.D.
Ilya S. Johnson, M.D. Manal S. Antoun, M.D. Ana R. Hernandez, M.D.
Paola A. Bordoni, D.O. Anna T. Davis, M.D.
Screening Questionnaire for Adult Immunization
For patient:
The following questions will help us determine which vaccines you may be given today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.
For Women:
It is important for you to have a personal record of your vaccines. If you don't have a personal record, ask your healthcare provider to give you one. Bring it with you every time you seek medical care