Vaccine Questionaire and Consent Form Adult Immunization 2023

_{Jarrettsville Pharmacy}

_{3714 Norrisville Rd P.O. Box 57}

_{Jarrettsville, MD 21084-1419}
Screening Questionnaire and Consent Form for Adult Immunization

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.
I. Patient Information:
Patient Name*
Address*

Address

Street Address Line 2

CityState

Zip
Phone*
DOB*

MonthDayYear
Date
Age*
Weight*
Allergies*
Insurance Provider*
ID#*
Primary Medical Practitioner*
Medical Practitioner Phone*
II. Vaccination Screening Questionnaire:

(Please answer all questions)
1. Is the person to be vaccinated sick today or have they recently tested positive for COVID-19?*

YesNoDon't Know
2. Have you ever received a passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*

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

YesNoDon't Know
4. Have you ever had a serious reaction after receiving a vaccination or injectable medication?*

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

YesNoDon't Know
6. Do you have a history of myocarditis, pericarditis, or multisystem inflammatory disorder (MIS-C or MIS-A)*

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

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

YesNoDon't Know
9. In the past 3 months, have you taken medications that affect your immune system, such as cortisone, 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
10. Have you had a seizure, a brain disorder or other nervous system problems (such as Guillian-Barré syndrome)?*

YesNoDon't Know
11. 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
12. For women: Are you breast feeding, pregnant, or is there a chance you could become pregnant during the next month?*

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

YesNoDon't Know
Did you bring your immunization record card with you?*

YesNo
_{It is important for you to have a personal record of your vaccinations. If you don't have a personal record, ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every time you seek medical care. Make sure your healthcare provider records all your vaccinations on it.}
III. Patient Consent:

I have read, or have had read to me, the Vaccination Information Statement (VIS) or EUA fact sheet regarding the vaccines(s) I am about to receive. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s) and the notification of my primary care physician. I fully release and discharge their offices, directors and employees from any liability for illness, injury, loss or damage which may result there from. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment. I understand that I should remain in the pharmacy for 15 minutes for observation in case there is an adverse reaction.
Patient Name (printed)*
Patient Signature*

Clear
Date*

MonthDayYear
Date
IV. Immunizations Given (Pick the vaccination you want to get):

https://www.cdc.gov/vaccines/hcp/vis/current-vis.html
Vaccine #1*
Vaccine #2
Vaccine #3
Request an Appointment Date and Time*
Should be Empty:

Screening Questionnaire and Consent Form for Adult Immunization

I. Patient Information:

II. Vaccination Screening Questionnaire:

III. Patient Consent:

IV. Immunizations Given (Pick the vaccination you want to get):