Briva Health Screening Questionnaire

Briva Health Screening Questionnaire - COVID 19 Vaccine
Please complete the following questions for the child recieving the vaccination.
Name

First Name Middle Initial Last Name
Date of Birth
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Gender
Race
Ethnicity
Household Primary Language
Screening Questionnaire
Are you between the ages of 5 and 11 years old?

Yes No
Are you 12 years old or older?

Yes No
Are you feeling sick today?

Yes No
In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or have you been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?

Yes No Unknown
Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?

Yes No Unknown
Date you received the last dose

Month Day Year
Date
Have you ever had an immediate allergic reaction (e.g., hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything?

Yes No Unknown
Do you have cancer, leukemia, HIV/AIDS or any other condition that weakens the immune system?

Yes No Unknown
Do you take any medications that affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments?

Yes No Unknown
Do you have a bleeding disorder, a history of blood clots or are you taking a blood thinner?

Yes No Unknown
Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?

Yes No Unknown
Have you received a previous dose of the Pfizer, Moderna, or Janssen vaccine?

Yes No Unknown
Date you received the vaccine

Month Day Year
Date
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Briva Health Screening Questionnaire - COVID 19 Vaccine