Fillable Vaccine Screening Questionnaire Template printable pdf download

MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA

For use of this form, see requiring document. Form is not valid without Requiring Document, Issuance Date, Local Form Number, and Edition Date.

REQUIRING DOCUMENT

LOCAL FORM TITLE

ISSUANCE DATE

Vaccine Screening Questionnaire

NAVMEDCENPTSVA INST

July 2011

6230.3a w/ch1

NMCP 6230/4 (NEW 7/11) Exception to NAVMED 6000/5 (09/2008)

Date

ADENOVIRUS, ANTHRAX, BCG, DTAP, HEPATITIS A, HEPATITIS B, HIB, HPV, INFLUENZA (INACTIVATED / FLUMIST ),

JEV, MMR, MENINGOCOCCAL, PNEUMOCOCCAL (PNEUMOVAX / PREVNAR) POLIO, PPD, RABIES, ROTAVIRUS, TD,

TDAP, TT, TYPHOID Vi, TYPHOID ORAL TABS, VARICELLA, YELLOW FEVER, ZOSTAVAX

( LIVE VIRUSES ARE BOLDED)

Do you have a weakened immune system because of drug treatment for organ transplant, cancer, rheumatology condition

Yes / No

(RA, Lupus, etc), Multiple Sclerosis, or HIV/AIDS or another disease that affects the immune system?

Have you been taking oral steroids for greater than two weeks?

Yes / No

3) If less than 21 years old – are you taking daily aspirin therapy? (specifically for Varicella and Influenza vaccine)

Yes / No / NA

Do you have a febrile illness (with a fever greater than 101)? If yes, delay vaccination.

Yes/No

Are you, or do you think you may be, pregnant?

Yes / No / NA

If Yes, the only vaccine routinely administered without a specialist order is injectable Influenza, PPD skin test.

Unknown

Have you received any other LIVE vaccinations in the past 4 weeks?

Yes / No

Have you received any blood product in the last 6 months?

Yes / No

If yes to any of the above, do not administer ANY live vaccine under routine immunization practice.

Print the names of your CURRENT MEDICATIONS, including over-the-counter and homeopathic remedies.

r No change or contraindications from SF-508

Medications reconciled by: _____________________

Do you have long-term health problems with: heart disease, lung disease, asthma, kidney disease, metabolic disease

(e.g. diabetes), anemia, neurological disorders and other blood disorders? If yes, DO NOT administer FluMist, follow

Yes / No

Injectable Flu Vaccine protocol. If seizures reported in children the PCM must review prior to DTaP.

Are you 50 years of age or older or a child 6 months to 2 years of age?

Yes / No

If Yes, follow protocol for administering Injectable Flu Vaccine.

Have you ever had Guillain-Barré Syndrome (a severe paralytic illness, also called GBS)?

Yes / No

If Yes, DO NOT administer flu, send to provider to evaluate prior to administering Menactra.

Do you have a vaccine component allergy? Such as Thimerosal, latex, gelatin, yeast, Streptomycin, Neomycin, phenol,

10)

or egg, etc. If yes, DO NOT administer vaccine that contains any of the above components.

Yes / No

If yes, refer to PCM for clarification, documentation and validation of allergy on file.

Have you ever had a serious reaction to a vaccine in the past that required medical treatment?

11)

Yes / No

If yes, refer to PCM for clarification, documentation and validation of VAER’s filed.

Have you read or have you had the Vaccine Information Statement (VIS) explained to you?

12)

Yes / No

Have you had a chance to ask questions and have they been answered to your satisfaction?

Have you had an allergy shot today? If yes, delay vaccination (interval should be at least 24 hours). Or are you

13)

Yes / No

scheduled to receive allergy therapy within the next 24 hours? (interval should be at least 24 hours).

14)

Have you ever had a positive PPD?

Yes / No

PRACTITIONER'S NAME

DATE

PRACTITIONER'S SIGNATURE

PATIENT'S IDENTIFICATION: (For typed or written entries, give:

HOSPITAL OR MEDICAL FACILITY

STATUS

Name - last, first, middle; SSN; Sex; Date of Birth; Rank/Grade.)

DEPARTMENT / SERVICE

RECORDS MAINTAINED AT

SPONSOR'S NAME

SSN

RELATIONSHIP TO SPONSOR

NAVMED 6000/5 (09-2008)

Vaccine Screening Questionnaire Template

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