Health Fitness Galore

	Yes	No	Don't know
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?
Did you ever experience any serious reaction after getting a vaccine?
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?
Did you have any brain or other nervous system problems?
Have you get vaccinated in the last 4 weeks?
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?

Do you have any of the followings? (select all that apply)

Lung diseaseHeart diseaseAsthmaKidney DiseaseDiabetesAnemiaBlood disorderNone
Do you have immunocompromised condition? (select all that apply)

CancerLeukemiaLymphomaHIV/AIDSTransplantAspleniaCSF leakCochlear implantNone
Have you ever tested positive for COVID-19?

YesNo
Test Date

MonthDayYear
Date
In the last 14 days, have you contacted with a person who was confirmed to have COVID-19?

YesNoNot sure
In the last 14 days, have you travelled internationally?

YesNo
Do you have any of the followings?

CoughColdFeverShortness of breathSore throatLoss of smell/tasteAbdominal pain/diarrheaAbnormal bruising or bleeding/eye redness
Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation
By signing this form,

I hereby accept that I have read and understood the acknowledgment letter provided above.

I declare that the information I have provided above is correct.

I am giving my full consent to get the COVID-19 vaccine of my own will.
Date

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Date
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