CDC Covid-19 Pre-Vaccine Patient Checklist
Please complete this BEFORE your Covid-19 vaccine visit
https://www.cdc.gov/vaccines/covid-19/downloads/pre-vaccination-screening-form.pdf
Please read through the following vaccine information for:
我們診所所接種的新冠疫苗是輝瑞。請閱覽一下網站關於這個疫苗以及副作用: 中文請閱
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Email *
Patient's Name  病人英文名字 *
Patient's Date of Birth 病人生日 *
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Appt Date  您的疫苗預約日期 *
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1. Is the person to be vaccinated sick today? 您(或孩子)今天生病吗? *
2. Has the person to be vaccinated ever received a dose of COVID-19 vaccine? 您(或孩子)是否已經接受過一劑 COVID-19 疫苗? *
2a. If yes, which vaccine product did you receive? 如果是,您(或孩子)接種了哪種疫苗產品?
2b. How many doses of COVID-19 vaccine were administered? 您(或孩子)已經接受了幾劑 COVID-19 疫苗?
3. Has the person to be vaccinated 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 caused hives, swelling, or respiratory distress, including wheezing.)   您(或孩子)是否對以下物質發生過過敏反應:(這可能包括需要腎上腺素或 EpiPen® 治療或導致您去醫院的重度過敏反應[例如,過敏症]。還包括可導致蕁麻疹、腫脹或呼吸窘迫的過敏反應,包括喘息。 ) *
Yes 是
No 否
Don't know 不知道
A component of a COVID-19 vaccine 新冠疫苗的组分
A previous dose of COVID-19 vaccine 既往接種過一劑 COVID-19 疫苗
4. Is the person to be vaccinated have a health condition or undergoing treatment that makes them moderately or severely immunocompromised? This would include, but not limited to, treatment for cancer, HIV, receipt of organ transplant, immunosuppressive therapy or high-dose corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant [HCT], or moderate or severe primary immunodeficiency. 您(或孩子)是否有病症或正在接受治療,使您的免疫功能受到中度或嚴重損傷? (這將包括針對癌症或艾滋病的治療、接受器官移植、免疫抑制療法或高劑量皮質類固醇、CAR-T-細胞療法、造血幹細胞移植 [HCT]、迪喬治症候群或濕疹血小板減少伴免疫缺陷) *
5. Has the person to be vaccinated received COVID-19 vaccine before or during hematopoietic cell transplant (HCT) or CAR-T-cell therapies? 自接種 COVID-19 疫苗以來,您(或孩子)是否接受過造血幹細胞移植 (HCT) 或 CAR-T-細胞治療? *
6. Has the person to be vaccinated ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (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 caused hives, swelling, or respiratory distress, including wheezing.) 您(或孩子)是否對另一種疫苗(不是 COVID-19 疫苗)或註射藥物有過敏反應?(這可能包括需要腎上腺素或 EpiPen® 治療或導致您去醫院的重度過敏反應[例如,過敏症]。還包括可導致蕁麻疹、腫脹或呼吸窘迫的過敏反應,包括喘息。)
*
7. Check all that apply to the person to be vaccinated: 勾選所有適用於您(或孩子)的選項: *
Required
A copy of your responses will be emailed to the address you provided.
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