CDC Prevaccination Checklist

Prevacccination Checklist

for COVID-19 Vaccines
For vaccine recipients: The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer "yes" to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explainit.
Patient Name *
Age *
Date *

Month Day Year
Date
1. Are you feeling sick today? *

Yes No Don't know
2. Have you ever received a dose of COVID-19 vaccine *

Yes No Don't know
If yes, which vaccine product did you receive?

Pfizer Moderna Janssen (Johnson & Johnson) Another product
3. Have you ever had an allergic reaction to:

(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing

A component of a COVID-19 vaccine including either of the following:
Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures *

Yes No Don't know
Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids. *

Yes No Don't know
A previous dose of COVID-19 vaccine. *

Yes No Don't know
A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction. *

Yes No Don't know
4. Have you ever had an allergic reaction to another vaccine (other than COVID-10 vaccine) or an injectable medication? (This wouldi nclude a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occured within 4 hours that caused hives, swelling, or respiratory distress, including wheezing. *

Yes No Don't know
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pt, venom, environmental, oral medication allergies. *

Yes No Don't know
6. Have you received any vaccine in the last 14 days? *

Yes No Don't know
7. Have you ever had a positive test for COVID-19 or has a doctor ever told you tht you COVID-19? *

Yes No Don't know
8. Have you received passive antibody therapy (monoclonal antibodies or convaslescent serum) as treatment for COVID-19? *

Yes No Don't know
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosupressive drugs or therapies? *

Yes No Don't know
10. Do you have bleeding disorder or are you taking a blood thinner? (eg. Aspirin, Clopidogrel (Plavix), Warfarin (Coumadin), Apixaban (Eliquis), Dabigatran (Pradaxa), Rivaroxaban (Xarelto), Enoxaparin (Lovenox), or others) *

Yes No Don't know
11. Are you pregnant or breastfeeding? *

Yes No Don't know
12. Do you have dermal fillers? *

Yes No Don't know
Signature *

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Prevacccination Checklist