Immunization Screening Questionnaire

Immunization Screening Questionnaire

Please complete this form to help us determine your eligibility for immunization at our pharmacy. We are located at 80 Lambert Lind Highway Suite 5 Warwick, RI 02886. Please call with any questions about this form (401) 530-6360. Upon completion, your form will be transmitted to the pharmacy electronically.
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Do you currently have a membership with Compass Core Pharmacy?
Which vaccine would you like to receive today? (Select all that apply)

Other
Please review the following: The questions in this form help us determine if there is any reason we should not give you a vaccination today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. Please ask your healthcare provider if you have any questions.
Have you had any allergic reactions to vaccines or medications?
Are you currently experiencing any fever or illness?
Have you received any immunizations in the past 4 weeks?
Do you have any chronic health conditions?
Have you ever had a serious reaction after receiving a vaccination?
Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak?
Are you on long-term aspirin therapy?
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?
Have you had a seizure or a brain or other nervous system problem?
Have you ever had Guillian-Barre Syndrome?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
Would you like us to notify your primary care provider of today’s immunization? If yes, please list:
Patient Signature (Please sign below to confirm your responses and consent to vaccination)
Date

MonthDayYear
Date
Should be Empty: