General Vaccine Questionnaire

General Vaccine Questionnaire
Patient Name *
Date of Birth *

Month Day Year
Date
Phone Number *
Consent for Administration of the following Vaccines: *

Influenza (Flu) Hepatitis A Hepatitis B Meningococcal Measles, Mumps, Rubella Tetanus, Diptheria, Pertussis Pneumococcal Herpes Zoster (Shingles) Human Papillomavirus
Age
Address *

Address

Street Address Line 2

City, State, Zip
Gender *

Male Female
Patient Social Security Number or Medicare Number
SCREENING QUESTIONNAIRE FOR IMMUNIZATION

For adult patients to be vaccinated: 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 Flu Vaccine fill out questions 1-4 only)
1. Is the person to be vaccinated sick today? *

YES NO
2. Does the person to be vaccinated have any allergies to medications, food, a vaccine *

YES NO
3. Has the person to be vaccinated ever had a serious reaction after receiving a vaccination in the past? *

YES NO
4. Has the person to be vaccinated ever had Guillain-Barré syndrome? *

YES NO
5. Does the person have any long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? *

YES NO
6. Does the person have cancer, leukemia, AIDS, or any other immune system problem? *

YES NO
7. Does the person take cortisone, prednisone, other steroids, or anti-cancer drugs, o *

YES NO
8. Has the person had a seizure or a brain or other nervous system problem? *

YES NO
9. During the past year, has the person received a transfusion of blood or blood products,or been given immune (gamma) globulin or an antiviral drug? *

YES NO
10. For women: Is the person pregnant or is there a chance she could become pregnant during the next month? *

YES NO
11. Has the person received any vaccinations in the past 4 weeks? *

YES NO
Patient Signature (Parent or guardian, if patient is under 18 years of age) *

Clear
Date *

Month Day Year
Date
Should be Empty:

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General Vaccine Questionnaire

SCREENING QUESTIONNAIRE FOR IMMUNIZATION