Vaccination Questionnaire

Vaccination Questionnaire
Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
OPTIONAL: PCP Name/Phone/Practice Name
OPTIONAL: Front Side of Patient's ID

Cancelof
OPTIONAL: Back Side of Patient's ID

Cancelof
OPTIONAL: Front Side of Patient's Insurance Card

Cancelof
OPTIONAL: Back Side of Patient's Insurance Card

Cancelof
Patient/Caregiver Authorization

I have been offered a copy of the Vaccine Information Statement(s) (VIS) checked above. I have read, or had explained to me, and understand the information in the VIS(s). I understand the benefits and risks of all vaccines to be given today. I asked that the vaccine(s) checked above be given to me or to the person named above for whom I am authorized to make this request. I fully release and discharge, Wellrock Pharmacy LLC, its affiliates, officers, directors, and employees from any liability related to the administration of these vaccines. I consent to inclusion of this immunization data in the Maryland Immunization Registry for myself or on behalf of the person named above.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relation to Patient
Name of Parent/Guardian/Caregiver (IF APPLICABLE)

First NameLast Name
Screening Questions
Do you feel sick today? (Fever of 101*F in the past 24 hours, cold, acute illness, body aches)
Have you ever had a serious or allergic reaction to a vaccine, vaccine component, medication, latex, or food?
History of fainting, seizures, encephalopathy, GBS, or other nervous system problems?
Is the patient immunocompromised? (Asthma, COPD, Diabetes, HIV/AIDS, History of Transplant, etc.)
In the past 3 months, has the patient taken medications that weaken the immune system or had radiation treatments? Such as cortisone, prednisone, other steroids, or anticancer drugs.
In the past year, has the patient received a transfusion of blood or blood products or IgG?
Is the patient pregnant or is there a chance they could become pregnant during the next month?
**IF PREGNANT:** What week of pregnancy?
Leave blank if you are not pregnant.
Has the patient received any vaccinations within the past 4 weeks?
**IF YES:** List vaccinations received in the past 4 weeks.
Do you have a bleeding disorder or take a blood thinner or aspirin-containing products?
Should be Empty:

Vaccination Questionnaire

Patient Information

Patient/Caregiver Authorization

Screening Questions