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Time Started
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Time Ended
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COVID-19 Vaccine Screening Form
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The following questions will help determine which vaccines may be given today. If a question is not clear, please ask.
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Are you sick today?
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Are you allergic to either Polyethylene Glycol or Polysorbate?
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Do you have a long term health problem with heart disease, kidney disease, metabolic disorder (e.g. diabetes), anemia or others?
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Do you have a long term health problem with lung disease or asthma? Do you smoke?
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Do you have allergies to medications, food (i.e. eggs), latex / any vaccine component (e.g. neomycin, formaldehyde, gentamicin)?
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Have you received any vaccinations in the past 4 weeks?
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Have you ever had a serious reaction after receiving a vaccination?
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Do you have a neurological disorder that affect the brain like seizures or have had a disorder that resulted from a vaccine
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Do you have cancer, leukemia, AIDS, or any other immune system problem? (you may be referred to your physician)
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Do you take prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
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During the past year, have you received a transfusion of blood or blood products, including antibodies?
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Are you a parent, family member, or caregiver to a new born infant?
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For women: Are you pregnant or could you become pregnant in the next three months?
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Did you bring your Immunization Record Card with you?
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COVID19 Vaccine Side Effects Experienced
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If you have received a COVID19 Vaccine before please specify the vaccine received
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Date of Dose 1 for COVID19 Vaccine
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Date of Dose 2 for COVID19 Vaccine
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Have you received your third dose of the COVID19 Vaccine?
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(Initial) patient acknowledgement to have answered questions truthfully to the best of knowledge
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Print Name
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Signature
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Office Use Only
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Vaccine 1: COVID-19 Vaccine Administered
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Lot # and Expiration Date:
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Name of who administered the vaccine and date:
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Site
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Due Next
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Vaccine 2: COVID-19 Vaccine Administered
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Lot # and Expiration Date:
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Name of who administered the vaccine and date:
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Site
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Vaccine 3: COVID-19 Vaccine Administered
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Lot # and Expiration Date:
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Name of who administered the vaccine and date:
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Site:
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Clinician's Notes
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Subjective (Freewrite)
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Objective: (Freewrite)
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Assessment: (Freewrite)
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Plan: (Freewrite)
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Billing Code for New Patient
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Billing Code for Established Patient
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