Screening Questionnaire for Vaccine Only Visits

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Your information is secure

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For parents/guardians:

The following questions will help us determine if your child is eligible to receive his or her vaccine(s) today.

If you answer “yes” to any question, it does not necessarily mean your child should not be vaccinated.

It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

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Patients Name* This field is required.

First Name

Middle Name

Last Name

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Patients Date of Birth * This field is required.

Date

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Your Name* This field is required.

First Name

Last Name

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Please note that if your child does not have an up-to-date physical, he or she will be ineligible to receive any vaccines today.

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1. Is your child up to date on his/her physicals?

YesNo

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2. Is the child sick today?

YesNo

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Please explain the symptoms your child is feeling today?

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3. Is the child allergic to eggs?

YesNo

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4. Has the child had a serious reaction to a vaccine in the past?

YesNo

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5. Has the child had the flu vaccine in the past? If so, what year was it last given?* This field is required.

Yes

No

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7. Has your child ever been diagnosed with Guillain-Barré Syndrome?

YesNo

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8. Has the child had a seizure, brain, or other nervous system problem?

YesNo

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9. Does the child have cancer, leukemia, AIDS, or any other immune system problem?

YesNo

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10. Has the child taken cortisone, prednisone, other steroids, anticancer drugs, or aspirin therapy? If so, when was the last date?* This field is required.

No

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11. Has the child received a transfusion of blood or blood products, or been given immune (gamma)globulin or an antiviral drug in the past year?

YesNo

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Your Child's Gender:

MaleFemale

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12. Is the child/teen pregnant or is there a chance of becoming pregnant during the next month?

YesNo

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13. Has the child received vaccinations in the past 4 weeks?

YesNo

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By signing below, I understand the benefits and risks cited, and ask that the vaccines indicated above be given to my child, for who I am responsible.

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