Screening Questionnaire And Consent Form
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2Clinic –Yes
No
Screening Questionnaire and Consent Form
Patient Information: (Patient to complete)*
*Patient Name: ____________________________*Date of Birth: _________ *Age: _____ *Phone# _________________
*Address: _______________________________ *City: ___________________________ *State: _____ *Zip:_________
*Gender: M or F *Which vaccine(s) would you like to receive today? _________________________________________
*Medical Conditions: ___________________________________________ *Enter Weight if less than 110 lbs.: ________
**FOR EMERGENCY USE ONLY**
*Primary Care Physician (PCP): _________________________________ *Dr. Phone: ____________________
*PCP address- City ________________________ State______ Zip Code____________
Email Address _______________________________________________________
________________________________________________________________________________________________________________________
The following questions will help us determine which vaccines may be given today. If a
Yes
No
Don’t Know
question is not clear, please ask your pharmacist to explain it.
Are you sick today?
Do you have a long term health problem with heart disease, kidney disease, metabolic disorder
(e.g. diabetes), anemia or other blood disorders?
Do you have a long term health problem with lung disease or asthma? Do you smoke?
Do you have allergies to medications, food (i.e. eggs), latex or any vaccine component (e.g.
neomycin, formaldehyde, gentamicin, thimerosal, bovine protein, phenol, polymyxin, gelatin,
baker’s yeast or yeast)?
Have you received any vaccinations in the past 4 weeks?
Have you ever had a serious reaction after receiving a vaccination?
Do you have a neurological disorder such as seizures or other disorders that affect the brain or
have had a disorder that resulted from a vaccine (e.g. Guillain-Barre Syndrome)?
Do you have cancer, leukemia, AIDS, or any other immune system problem? (in some
circumstances you may be referred to your physician)
Do you take prednisone, other steroids, or anticancer drugs, or have you
had radiation treatments?
During the past year, have you received a transfusion of blood or blood products, including
antibodies?
Are you a parent, family member, or caregiver to a new born infant?
For women: Are you pregnant or could you become pregnant in the next three months?
Did you bring your Immunization Record Card with you?
Have you had the following vaccines:
Yes
No
Don’t Know
•
Pneumococcal Vaccine-- *you may need two different pneumococcal shots*
•
Shingles Vaccine
•
Whooping Cough (Tdap) Vaccine
6-2016
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