RAF - Hepatitis B Vaccine

Hepatitis B Vaccine - Risk Assessment Form
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*

MaleFemale
Phone Number*
Email*
Please check your email address is correct
Address*

Street Address

CityState

Post Code
Are you going to be travelling?*

YesNo
When are you travelling*
Which Country(ies) are you travelling to*
How many days will you be there*
Medical History
Are you feeling unwell today?

YesNo
Do you have any allergies (e.g. eggs, antibiotics, nuts, medications)?*

YesNo
Please specify*
Have you, or anyone in your family, had any allergies or severe reactions to previous vaccinations?*

YesNo
Have you received any vaccinations within the last 4 weeks?*

YesNo
Please specify*
Do you feel any stress related reactions (e.g. feeling faint) when receiving a vaccine?*

YesNo
Please specify*
Are you or your partner pregnant or planning a pregnancy?*

YesNoN/A
Are you breast-feeding?*

YesNoN/A
Have you been told by your doctor you have an intolerance to any sugars, including a rare hereditary problem of fructose intolerance?*

YesNo
Do you have any ongoing medical problems or chronic conditions?*

NoSickle cellKidney diseaseMyasthenia gravisDiabetesPsoriasisLiver diseaseEpilepsyHigh blood pressureAsthmaPhenylketonuriaOther (please specify)
Have you had past or recent surgery? E.g. open-heart surgery, transplant surgery, spleen or thymus gland removal.*

YesNo
Please specify*
Do you have a bleeding disorder (e.g. blood dycrasias), including taking any medication that thins your blood (anticoagulants)?*

YesNo
Please specify*
Do you have, or have you had, a condition that could impair your immune system? Or in the last 12 months, have you taken any medication or had treatment that could impair your immune system?*

NoHad solid organ/bone marrow/stem cell transplantReceived chemotherapy or radiotherapyTaken immunosuppressantAre currently on or have taken high dose steroidsHave HIV/AIDSAre immunocomprimisedHave had your spleen removedOn dialysisHave cancer or had cancer in the pastOther (please specify)
Do you suffer from thymus dysfunction or have had your thymus removed, including open heart surgery?*

YesNo
Do you have any cerebral disorders (e.g. epilepsy or stroke)?*

YesNo
Please specify*
Do you have a history or family history of convulsions (fits) or epilepsy?*

YesNo
Do you have or have you had any liver problems?*

YesNo
Please specify*
Do you have or have you had any kidney problems?*

YesNo
Please specify*
Have you, or a first degree relative (parents, brother, sister, or child), ever experienced any mental health issues, even mild anxiety, or depression?*

YesNo
Please specify*
Do you take any current or repeat medicines, including any medication you buy over the counter?*

YesNo
Please specify*
Do you have any past or recent medical history of note?*

YesNo
Please specify*
Please select all previous vaccines that you have received?

BCGCholeraCovid-19DiphtheriaHepatitis AHepatitis BInfluenzaJapanese EncephalitisMeningitis ACWYMMRPolioRabiesShinglesTetanusTick-borne EncephalitisTyphoidYellow FeverOther (please specify)
This vaccine may not be suitable for you, please contact us for further advice, by email: info@myprivatechemist.com, or phone: 02039879202.
Our Clinic:

My Private Chemist

Longcroft House

2-8 Victoria Avenue

EC2M 4NS
Should be Empty:

Hepatitis B Vaccine - Risk Assessment Form

Patient Information

Medical History