Lopez Island Pharmacy Vaccination Questionnaire Ver 5.0

Vaccine to receive? * Please only select one choice of what you have made an appt. for*

Flu Vaccine 2025/2026Shingles(Shingrix)Tetanus/Pertussis(Whooping Cough)Pneumonia( Either Pneumox Vax 23 OR Prevnar 20)RSV VaccineUNAVAILABLE Hepatitis AUNAVAILABLE Hepatitis BRabiesTyphoid(Vivotif) Oral Capsules (Valid for 5 years)Typhoid(Typhim) Injection (Valid for 2 years )
If you are requesting a Tetanus(Whooping Cough) vaccination and you need immediate treatment, example: injury or an animal bite please call the pharmacy as soon as possible (360-468-2616). If after hours call 360-468-2616 and follow the prompts and you will be directed on how to reach us after-hours.

Please continue filling out this consent form.
Shared Clinical Decision Making(SCDM)

RSV Vaccination for Adults 60 years and Older

• Respiratory syncytial virus (RSV) is a cause of severe respiratory illness across the lifespan. Each year in the
United States, RSV leads to approximately 60,000-160,000 hospitalizations and 6,000-10,000 deaths among
adults 65 years and older.

• Adults 60 years of age and older now have the option to receive one dose of RSV vaccine based on a SCDM
process between a patient and their health care provider.

• Consider multiple factors when discussing RSV vaccination with your patients. SCDM recommendations are
optional and are informed by whether the patient has any risk factors for severe RSV disease; a patient’s
risk of exposure to RSV; a patient’s preferences for RSV vaccination; and the clinical discretion of the health
care provider.
Do you have any(Select All That Apply) of these underlying medical conditions associated with increased risk for severe RSV disease?

Chronic Lung Disease (e.g. COPD and asthma)?Chronic cardiovascular disease (e.g. CHF-Chronic Heart Failure and Coronary Artery Disease)?Chronic OR progressive neurologic or neuromuscular conditions?Chronic kidney disease (CKD)?Chronic Liver disease (CLD)?Diabetes Mellitus?Moderate or severe immunocompromise?Chronic hematologic disorders?ANY underlying condition that a provider determines might increase the risk of severe RSV disease?
Other factors associated with increased risk for severe RSV disease include (Select All that Apply) :

Frailty OR advanced age, as determined by a healthcare provider?Residence in a nursing home OR other long-term care facility?Any underlying factor as provider determines might in increase the risk of severe RSV disease?
Other points to consider:

• Serious neurologic conditions, including Guillain-Barré syndrome (GBS), have been reported after RSV
vaccination in clinical trials. However, it is unclear whether the vaccine caused these events.

• Persons with history of severe allergic reaction (e.g., anaphylaxis) to any component of RSV vaccine should
not receive the vaccine.

Source: https://www.cdc.gov/vaccines/vpd/rsv/downloads/provider-job-aid-for-older-adults-508.pdf
Is Lopez Island Medical Center your "Primary Provider"?

YesNo
Primary Care Provider and Office Phone
Lopez Island Medical Center 360-468-2245 PLEASE CONTINUE
Then please enter your "Primary Care" provider name and phone number.
Enter your Primary Care provide and phone number.
For Patients: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 today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.
1. Are you sick today with a temperature of 100 or higher? *

YesNoDon't Know
If "Yes" to #1 please describe
Please describe why you answered YES
If "Don't Know" to #1 please describe.
Please describe why you answered Don't Know
2. Are you allergic to eggs?

YesNoUnsure
3. Do you have any allergies to Medications, Food, Latex or a vaccine component?*

YesNoDon't Know
If "Yes" to #3 please describe.*
Describe your allergy?
If "Don't Know" to #3 please describe.*
Please describe why you answered Don't Know
4. Have you ever had a serious reaction after receiving a vaccination?

YesNoDon't Know
If "Yes" to #4 please describe.
Please describe what happened
If "Don't Know" to #4 please describe.
Please describe why you answered Don't Know
5. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease(diabetes), anemia or other blood disorders?*

YesNoDon't Know
If "Yes" to #5 please describe.
Describe your long-term health problems
If "Don't Know" to #5 please describe.
Please describe why you answered NO
6. Do you have Cancer, Leukemia, AIDS or any other Immunological disorder?

YesNoDon't Know
If "Yes" to #6 please describe.
Describe your condition
If "Don't Know" to #6 please describe.
Please describe why you answered NO
7. Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?

YesNoDon't Know
If "Yes" to #7 please describe.
Describe the medications or treatment
If "Don't Know" to #7 please describe.
Please describe why you answered NO
8. Have you had a seizure, brain, or other nervous system problem?

YesNoDon't Know
If "Yes" to #8 please describe.
Describe why you answered YES
If "Don't Know" to #8 please describe.
Please describe why you answered NO
9. During the past year, have you received a transfusion of blood or blood products ,or been given immune (gamma) globulin or an antiviral drug, (This does NOT included ANY Covid Vaccinations)

YesNoDon't Know
If "Yes" to #9 please describe.
Describe why you answered YES
If "Don't Know" to #9 please describe.
Please describe why you answered NO
10. Have you received any vaccinations in the past 4 weeks?

YesNoDon't Know
If "Yes" to #10 please describe.
Describe the vaccinations you received
If "Don't Know" to #10 please describe.
Please describe why you answered NO
11. For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNoDon't Know
If "Yes" to #11 please describe.
Describe how far along you are or any other information you think we need
If "Don't Know" to #11 please describe.
Please describe why you answered NO
12.. Have you ever had ANY arm pit lymph nodes removed?*

YesNo
13. Do you have a neurological disorder such as seizures or other disorders that affect the brain or have had a disorder that resulted from a vaccine (e.g. Guillain-Barre Syndrome)?*

YesNo
14. Have you ever received a flu vaccination before?*

YesNo
15. Are you taking ANY blood-thinners( example- Warfarin, Coumadin, Xarelto, Eliquis,Pradaxa)*

YesNoUnsure
It is important for you to have a personal record of your vaccinations. If you don’t have a personal record,ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every time you seek medical care. Make sure your healthcare provider records all your vaccinations on it.

All our vaccinations are logged on the Washington Immunization System and can be accessed by most health care providers should they need to see your records
All vaccinations are submitted to the Washington State Health Department Vaccination Database UNLESS you specifically opt out.*

I consent to this vaccination being submitted to the Department of Health DatabaseI do NOT consent to my vaccination being sent to the Department of Health Database
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