Child Vaccine Screening Checklist
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Is the child sick today?
Yes
No
Don't know
Does the child have allergies to medications, food, a vaccine component, or latex?
Yes
No
Don't know
Has the child had a serious reaction to a vaccine in the past?
Yes
No
Don't know
Does the child have a long-term health problem with lung, heart, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Is he/she on a long-term aspirin therapy?
Yes
No
Don't know
If the child to be vaccinated is 2 through 4 years of age, has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?
Yes
No
Don't know
Has the child, a sibling, or a parent had a seizure; has the child had brain or other nervous system problems?
Yes
No
Don't know
Does the child have cancer, leukemia, HIV/AIDS, or any other immune system problem?
Yes
No
Don't know
Does the child have a parent, brother, or sister with an immune system problem?
Yes
No
Don't know
In the past 3 months, has the child taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or had radiation treatments?
Yes
No
Don't know
In the past year, has the child received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
Yes
No
Don't know
Is the child/teen pregnant or is there a chance she could become pregnant during the next month?
Yes
No
Don't know
Has the child received vaccinations in the past 4 weeks?
Yes
No
Don't know
Form completed by
Date
-
Month
-
Day
Year
Date
Submit
Submit
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