The following questions will help us determine your eligibility to be vaccinated today.
Are you feeling sick today? If Yes, please circle if you are experiencing any of the following: new fever, cough, diarrhea, vomiting Do you have any allergies to medications, food (e.g. eggs or egg products), latex, vaccines, or vaccine component (e.g. neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin, baker's yeast or yeast?) If Yes, please list:
Have you ever had any serious reaction to any vaccinations, including fainting and feeling dizzy?
Have you ever had a health problem with lung, heart, kidney, liver, or metabolic disease (e.g. diabetes), neurologic or neuromuscular disease, asthma, anemia or another blood disorder? Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré
Syndrome (a condition that causes paralysis) or other nervous system problem?
Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a physician's office or hospital?
For women only: Are you pregnant or considering becoming pregnant in the next month?
For Tdap or adult Td only: Do you have an open wound, puncture or tissue tear that prompted you to get a tetanus shot?