RSV (Respiratory Syncytial Virus) Vaccine

Screening Checklist PATIENT for Contraindications to RSV (Respiratory Syncytial Virus) Vaccine
Name*

First NameLast Name
Date*

MonthDayYear
Date
Who is your Primary Care Physician?
Screening Checklist to RSV (Respiratory Syncytial Virus) Vaccine
The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable influenza vaccination today. If you answer "yes" to any questions, it does not necessarily mean you (or your child) 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.

VIS Date: 7/24/23
1. Is the person to be vaccinated sick today?*

YesNoDon't Know
2. Does the person to be vaccinated have an allergy to an ingredient in*

YesNoDon't Know
3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?*

YesNoDon't know
4.Has the person to be vaccinated ever had Guillain Barre syndrome?*

YesNoDon't Know
5. Has the person to be vaccinated ever felt dizzy or faint before, during, or after a shot*

YesNoDon't Know
6. Is the person to be vaccinated anxious about getting a shot today?*

YesNoDon't know
Which Arm?*

Left DeltoildRight Deltoid
Signature*

Powered by Jotform SignClear
DATE*

MonthDayYear
Vis Date

07/24/2023
Should be Empty:

Screening Checklist PATIENT for Contraindications to RSV (Respiratory Syncytial Virus) Vaccine