Covid-19 Pre-Vaccine Checklist: Family Members
Please complete this BEFORE your Covid-19 vaccine visit
https://www.cdc.gov/vaccines/covid-19/downloads/pre-vaccination-screening-form.pdf
https://www.immunize.org/catg.d/p4065.pdf
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Your Name *
Your Date of Birth *
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Appt Date *
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Our office has the Moderna Covid-19 Vaccine. Please look through (or download) the following two links on the vaccine and possible side effects:
https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html
1. Are you feeling sick today? *
2. Have you ever received a dose of COVID-19 vaccine? *
2a. If yes, which vaccine product did you receive?
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3. Have you ever had an allergic reaction to: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital.It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.) *
Yes
No
Don't know
COVID-19 vaccine component: Polyethylene glycol (PEG), which is found in some medications (eg, laxatives and preparations for colonoscopy)
COVID-19 vaccine component: Polysorbate, which is found in some vaccines, film coated tablets, and IV steroids
A previous dose of COVID-19 vaccine
A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19vaccine component, but it is not known which component elicited the immediate reaction.
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (including a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.) *
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies. *
6. Have you received any vaccine in the last 14 days? *
7. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? *
7a. If so, when was your positive COVID-19 test?
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8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? *
8a. If so, was it in the last 3 months?
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9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? *
10. Do you have a bleeding disorder or are you taking a blood thinner? *
11. Do you have a history of or a risk factor for a blood clotting disorder? *
12. Are you pregnant or breastfeeding? *
13. Do you have dermal fillers? *
14. 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? *
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