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.
Email Address*
example@example.com
Do you currently have a membership with Compass Core Pharmacy?*

YesNo
Which vaccine would you like to receive today? (Select all that apply)*

Influenza (65+)Influenza (6 months+)COVID-19PneumoniaTDAPHepatitis BShinglesMeningitisOther
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?*

YesNoNot Sure
Are you currently experiencing any fever or illness?*

YesNo
Have you received any immunizations in the past 4 weeks?*

YesNo
Do you have any chronic health conditions?*

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

YesNo
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?*

YesNo
Are you on long-term aspirin therapy?*

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

YesNo
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?*

YesNo
Have you had a seizure or a brain or other nervous system problem?*

YesNo
Have you ever had Guillian-Barre Syndrome?*

YesNo
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*

YesNo
For women: Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNo
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)*

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Date*

MonthDayYear
Date
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