[Old Forge Pharmacy] Screening Questionnaire for Adult Vaccination

Name*

First NameLast Name

Date of Birth*

Date

Today's Date*

Date

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 get a vaccine. It just means that your health care provider may ask you more questions. If a question is not clear, please ask your health care provider to explain it.

Are you sick today?*

YesNoDon't know

Do you have allergies to food, latex, medications, or any vaccine?*

YesNoDon't know

Have you ever had a serious reaction after receiving a vaccination?*

YesNoDon't know

Have you had a seizure, or brain or nerve problem?*

YesNoDon't know

Do you have a health problem with asthma, lung disease, heart disease,kidney disease, metabolic disease such as diabetes, or a blood disorder?*

YesNoDon't know

Do you have cancer, leukemia, AIDS, or any other immune system problem?*

YesNoDon't know

During the past year, have you received a transfusion of blood or blood products,or been given a medicine called immune (gamma) globulin?*

YesNoDon't know

For women: Are you pregnant or is there a chance you could become pregnantduring the next 3 months?*

YesNoDon't know

Have you received any vaccinations in the past 4 weeks?*

YesNoDon't know

Did you bring your vaccination record card with you?*

YesNo

It is important for you to have a personal record of your vaccinations. If you don’t have a record card, ask your health care provider to give you one. Bring this record with you every time you seek medical care. Keep this card in your wallet or purse, and make sure your health care provider records all of your vaccinations on it.