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Have you received a previous does of any COVID-19 Vaccine?
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If yes, which manufacturer's vaccine did you receive?
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If Yes, When did you receive vaccine?
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Covid-19 Screening Questions
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Do you currently have any Covid-19 symptoms? Ex: cough, sore throat, body aches, fever, diarrhea, vomiting
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If yes, explain.
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Have you had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine?
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If yes, explain.
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Do you carry and Epi-pen for emergency treatment of anaphylaxis?
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If yes, explain.
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For women, are you pregnant or is there a chance you could become pregnant?
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If yes, explain.
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For women, are you breastfeeding?
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If yes, explain.
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Have you had any other vaccines in the past 14 days?
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If yes, explain.
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In the past two weeks, have you tested positive for COVID-19?
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If yes, explain.
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Have you had any of the following symptoms in last 10 days?
• • •
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If yes, explain.
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Have you received passive antibody therapy as treatment for COVID-19?
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If yes, When?
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Immunization Screening Guidance for COVID-19 Vaccine
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Do you have allergies or reactions to any medications, foods, vaccines, or latex?
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If yes, explain.
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Are you immunocompromised or on a medicine that affects your immune system?
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If yes, explain.
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Do you have a bleeding disorder or are you on a blood thinning medication?
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If yes, explain.
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