Vaccine Questionnaire and Consent Form for Child and Teen 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*
Format: (000) 000-0000.
DOB*

MonthDayYear
Date
Age*
Weight*
Allergies*
Insurance Provider*
ID#*
Primary Medical Practitioner*
Medical Practitioner Phone*
Format: (000) 000-0000.
II. Vaccination Screening Questionnaire:

(Please answer all questions)
1. Is the child sick today or recently tested positive for COVID-19?*

YesNoDon't Know
Has the child ever received a passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*

YesNoDon't Know
3. Does the child have allergies to medications, food, a vaccine component or latex?*

YesNoDon't Know
4. Has the child had a serious reaction to a vaccination in the past?*

YesNoDon't Know
5. Does the child have a long-term health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, a complement component deficiency, a cochlear implant or a spinal fluid leak? Is he/she on long term aspirin therapy/blood thinner?*

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

YesNoDon't Know
7. If the child to be vaccinated is 2 through 4 years of age, has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?*

YesNoDon't Know
8. If your child is a baby, have you ever been told he or she has had intussusception?*

YesNoDon't Know
9. Has the child, a sibling, or a parent had a seizure; has the child had brain or other nervous system problems (such as Guillain-Barre syndrome)?*

YesNoDon't Know
10. Does the child have cancer, leukemia, HIV/AIDS, or any other immune system problem?*

YesNoDon't Know
11. Does the child have a parent, brother, or sister with an immune system problem?*

YesNoDon't Know
12. In the past 3 months, has the child taken medications that affect the immune system such asprednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or had radiation treatments?*

YesNoDon't Know
13. In the past year, has the child received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

YesNoDon't Know
14. Is the child/teen breast feeding, pregnant, or is there a chance she could become pregnant during thenext month?*

YesNoDon't Know
15. Has the child received vaccinations in the past 4 weeks?*

YesNoDon't Know
_{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*
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):