Section II. Questionnaire for Immunization
Please select the correct option below:
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today?
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?
Was the severe allergic reaction after receiving a COVID-19 vaccine?
Was the severe allergic reaction after receiving another vaccine or another injectable medication?
Have you received another vaccine in the last 14 days?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?
For women: Are you breastfeeding?