covid vaccination checklist 23-24 pdf

Rxxpress Health Mart Pharmacy Screening Checklist for Contraindications to COVID-19 (SARS-COV-2) Vaccine

Name*

First NameLast Name

Date of Birth*

Date of Birth

Who is your primary care physician?

For patients (both children and adults) to be vaccinated: The following questions will help us determine if there is any reason we should not give you or your child inactivated COVID-19 (SARS-COV-2) 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.

Have you ever received a dose of COVID-19 vaccine?*

YesNoDon't Know

How many doses of the COVID-19 vaccine have you received?

0123 or more

If YES, which vaccine product did you receive? (Check all that apply)

ModernaPfizerN/A

Has it been at least 2 months since your last COVID-19 vaccine?*

YesNo

Date of Last Covid-19 Vaccine Date*

Did you bring your vaccination record card or other documentation?*

YesNoDon't Know

Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?*

YesNoDon't Know

Have you had any immediate allergic reactions (defined as within 4 hours) to the following questions A-D:(Note: if you aren’t sure of any of the answers below, please respond ‘NO.”)

A. A previous dose of mRNA COVID-19 vaccine?*

YesNo

B. A component of an mRNA COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?*

YesNo

C. Polysorbate?*

YesNo

D. Another vaccine (other than COVID-19 vaccine) or an injectable medication for another disease?*

YesNoIf YES, have you discussed with your physician if its safe for you to get a mRNA Covid-19 vaccine?(please write Yes or No Below

Are you currently experiencing acute illness and/or new or worsening high fever, chills,body aches, cough, sore throat, diarrhea, vomiting, loss of taste or smell, or shortness of breath, congestion, or a runny nose?*

YesNoDon't know

Do you have a history of Guillain-Barre Syndrome (GBS)?*

YesNoDon't know

Do you have a history of immune mediated syndrome characterized by clotting and low platelet count (e.g., heparin-induced thrombocytopenia (HIT)?*

YesNoDon't know

Do you have current or planned immunosuppression: HIV infection, organ transplant recipient, treated with TNF-alpha antagonist, steroids, or other immunosuppressive medication?*

YesNoDon't know

Have you received a hematopoietic cell transplant (HCT) or CAR-T-cell therapy since receiving COVID-19 vaccine?*

YesNoDon't know

Females only: Are you pregnant at this time or do you plan to become pregnant in the next 2 months?

YesNoDon't know

Females only: Are you currently breastfeeding?

YesNoDon't know

Which Arm*

RightLeft

FORM COMPLETED BY*

DATE*

Date

Signature

There are no appointments, you can come into the pharmacy for your vaccine anytime during normal store hours. We only ask you come in atleast an hour before we close to ensure you have no reaction to the vaccine.