2024 Pre-Vaccination Questionnaire (COVID/Flu)

2024 Pre-Vaccination Questionnaire (COVID/Flu)
PLEASE READ CAREFULLY

1. Complete this form for each person receiving a shot who is NOT seeing a physician today. This is needed to ensure nothing has changed with your health.

2. Answer carefully: this form is automated based on your answers.

3. Mistakes can't be corrected: you will need to complete the form again if answered incorrectly.
Who is this form being completed for? Who is receiving a vaccine?*

I am a PARENT getting a flu vaccine MYSELF, I am answering for myself (flu vaccine offered only)I am completing this form for a minor child OR I am an 18+ pediatric patient today (either Flu or COVID offered)
The choice you made above means "I, a parent, am getting a flu shot today and I am filling this out for myself, not my child."

If you meant to fill this out for your child, choose the other option above.

If you are an 18+ pediatric patient, you also need to choose the other option above.
Date of Scheduled Vaccination Appointment:*

MonthDayYear
Date
Location of vaccine appointment:*
Patient Information
Name of Patient*

First NameLast Name
Date of Birth*
Flu and COVID vaccines are only available for children 6 months of age and older.
Choose the patient's age group:*

6 months- under 5 years5 years - under 12 years12 years and up
Is this person receiving a COVID19 Shot? (Available for children only)*

YesNo

Flu Prevaccination Screening: Adult

IF YOU ARE NOT AN ADULT PARENT completing this for a vaccine for yourself, please exit and instead answer the first question as"

"I am completing this form for a minor child or I am an 18+ pediatric patient today (either Flu or COVID offered)"
1. Have you ever had a serious reaction to a previous dose of influenza vaccine, or hada life-threatening allergy to any ingredient in the vaccine?*

NoYes
2. Have you ever had a serious reaction to a previous dose of influenza vaccine, or had a life-threatening allergy to any ingredient in the vaccine?*

NoYes
3. Are you over the age of 65?*

NoYes
4. Have you had a fever or moderate or severe illness in the past 2 days?*

NoYes

Consent and Acknowledgment
A copy of a Vaccine Information Sheet or a fact sheet has been provided to me corresponding to the vaccine that I will receive. I have read the information and I have had the opportunity to ask questions and by which answers were given to me to my satisfaction. I understand that the vaccine has corresponding benefits and risks and I assume full responsibility for its effect or reaction to my body.

I request that the vaccine be given to me or to the above-named patient for whom I am authorized. I have been advised and I understand that I have to remain within the premises for 15 minutes after I have been administered the vaccine.

I understand that in case side effects start to manifest, I shall call my doctor, the pharmacy, and/or 911.

I understand that my health information may be required to be disclosed to the physician responsible for this protocol of gathering information of people vaccinated (if applicable) for the benefit or use of my insurance plan, health services, medical facilities, my physician, federal registries, for the purpose of this and other procedures or treatment. I also understand that this disclosure shall be limited to as previously stated and shall not be used for other purposes not authorized by me.
Representation*

I am signing this form in my own full capacity.I am the authorized legal guardian/representative of the above-named patient. I am signing this form as an express giving of my consent for and on behalf of the patient.
Name of Adult patient/Legal Guardian completing Form*

First NameLast Name
var 1 (do not delete)
var 2 (do not delete)
var 3
date field 1

MonthDayYear
Date
date field 2

MonthDayYear
Date
date field 3

MonthDayYear
Date
Parent Email
example@example.com
Should be Empty:

2024 Pre-Vaccination Questionnaire (COVID/Flu)

Consent and Acknowledgment