Screening/Consent for Vaccination
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Legal name (First, Middle, Last) *
Birthdate *
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DD
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Age: *
Phone Number *
Address *
City, Zip Code *
Gender *
Required
Maiden Name (if applicable)
Mother's Maiden Name (used to Verify Recipient in NESIIS) *
Are you sick today? *
Do you have allergies to medications, gelatin, yeast, eggs, latex or any vaccine? *
Have you ever had a serious reaction to a vaccine in the past? *
Have you ever had a seizure or a neurological problem? *
Have you ever had Guillian-Barre syndrome? *
Do you take cortisone, prednisone, other steroids, anticancer drugs or X-Ray treatment? *
Are you pregnant or is there a chance you could become pregnant during the next 3 months? *
Do you have cancer, leukemia, AIDS or any other immune system problem? *
Have you been given immune (gamma) globulin or an antiviral drug in the past 6 months? *
Have you had chicken pox? *
Have you received Vaccinations in the past 4 weeks? *
Have you received a transfusion of blood or blood products in the past 6 months? *
Are you American Indian or Alaskan Native? *
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