Adult Vaccine Screening Form
Patient Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have allergies to medications, food, a vaccine component, or latex?
*
Yes
No
Don't know
Have you ever had a serious reaction after receiving a vaccination?
*
Yes
No
Don'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?
*
Yes
No
Don't know
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
*
Yes
No
Don't know
Do you have a parent, brother, or sister with an immune system problem?
*
Yes
No
Don'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?
*
Yes
No
Don't know
Have you had a seizure or a brain or other nervous system problem?
*
Yes
No
Don't know
During the past year, have you received a transfusion of blood or blood products, or been given immune globulin or an antiviral drug?
*
Yes
No
Don't know
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
*
Yes
No
Don't know
Have you received any vaccinations in the past 2 weeks?
*
Yes
No
Don't know
INSURANCE INFORMATION
Please enter the information below found on your insurance card.
Cardholder Name
*
ID Number
*
RxBIN
*
RxPCN
*
RxGRP
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: