COVID-19 Vaccine General Screen
Thank you for your interest in volunteering for a COVID-19 vaccine clinical trial. Please answer the questions below about your medical history, and one of our CRA associates will call you with further information. Your data will not be shared with any third parties.
Sign in to Google to save your progress. Learn more
Have you ever tested positive for COVID-19? *
Have you had to change medications in the last three months or are you currently being evaluated for a new medical condition? *
Have you take a medication that was intended to prevent COVID-19? *
Do you have a history of immunosuppresive or immunodeficient conditions? *
Do you have any history of cancer? *
Do you have a history of allergic reactions to medications or vaccines? *
Do you have a history of Gullian-Barre Syndrome? *
Have you received any blood or blood products in the last three months, or donated blood in the last month? *
Do you have a history of any psychiatric conditions? *
Have you attempted suicide or had suicidal thoughts in the last year? *
Do you have a history of a bleeding disorder that would prevent you from receiving an injection? *
Are you currently pregnant or breast feeding? *
Have you participated in a clinical trial in the last 28 days? *
Please list all medications taken daily or as needed *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms