Screening Checklist for Contraindications to Vaccines for Adults

4117 Main Street • Whitehall, PA • 18052
P: 610-440-6337 • F: 610-440-6338
Screening Checklist for Contraindications to Vaccines for Adults
Patients Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Which vaccine(s) are you interested in receiving today? PLEASE CALL TO CONFIRM AVAILABILITY FOR SAME DAY APPOINTMENT*

FluPneumoniaShinglesMeningitisHepatitis A/BChicken PoxTyphoidHPVTetanusOther
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. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.
Are you sick today?*

YesNoDon't Know
Do you have allergies to medications, food, a vaccine component, or latex?*

YesNoDon't Know
Have you ever had a serious reaction after receiving a vaccination?*

YesNoDon't Know
Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?*

YesNoDon't Know
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*

YesNoDon't Know
Do you have a parent, brother, or sister with an immune system problem?*

YesNoDon't Know
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?*

YesNoDon't Know
Have you had a seizure or a brain or other nervous system problem?*

YesNoDon't Know
During the past year, have you received a transfusion of blood or blood products,or been given immune (gamma) globulin or an antiviral drug?*

YesNoDon't Know
For women: Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNoDon't Know
Have you received any vaccinations in the past 4 weeks?*

YesNoDon't Know
Form Completed By (IF OTHER THAN THE PATIENT):

First NameLast Name
Appointment*
Which arm would you like to get the injection in?*

Right ArmLeft Arm
PRIMARY CARE PROVIDER

First NameLast Name
PCP Phone Number
Please enter a valid phone number.
Email (OPTIONAL)*
example@example.com
Signature*

Clear
Should be Empty: