Looking for a Screening Checklist Templates? Download it for free!

Jersey County Health Department

1307 State Hwy 109, Jerseyville IL 62052

Name

Last:

First:

M.I.:

Date of Birth: ___/___/___ Age:

Address:

County:

City:

State:

Zip:

Phone:

Guardian:

Physician:

Insurance Information

Medicaid

Medicare

Private Insurance:

_______

Self Pay

Uninsured or Under-insured (qualifies for VFA program)

Put an “x” in the box below to indicate that you have the HIPAA information.

HIPAA –

I understand a Notice of Privacy Practices is available at my request. Under the Healthcare Insurance Portability

and Accountability Act, I authorize to disclose my Immunization Record to my physician and/ or school. I also authorize the

following person(s) to have access to my records:

(It’s OK if you don’t write anyone’s name)

Adult Screening Checklist for Contraindications to Vaccines

The following questions will help us to determine which vaccines you may be given today. If you answer “yes” to any question,

it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is

not clear, please ask clinic staff to explain it.

Don’t

Yes

Know

Are you sick today?

Do you have allergies to medications, food (including eggs), a vaccine component, or latex?

If yes, list here:

Have you ever had a serious reaction after receiving a vaccination?

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?

In the past 3 months, have you taken medications that weaken your immune system, (cortisone,

prednisone, other steroids, or anticancer drugs) or have you had radiation treatments?

Have you had a seizure or a brain or other nervous system problem,

including Guillain-Barre syndrome

During the past year, have you received a transfusion of blood or blood products, or been given

immune (gamma) globulin or an antiviral drug, including influenza antiviral medications?

For women: Are you pregnant or breastfeeding, or is there a chance of you becoming pregnant

during the next month?

Have you received any vaccines in the past 4 weeks?

10. Do you live with or expect to have close contact with a person whose immune system is severely

compromised and who must be in protective isolation (such as for a bone marrow transplant)?

11. Do you have any of the following health problems? Please circle:

Lung disease (including asthma)

Immunocompromised

Kidney disease

Metabolic disease (such as diabetes)

Neurologic or neuromuscular disorder

Liver disease

Heart disease (except isolated high blood pressure)

Blood Disorder

None

12. Your age (circle one):

18-49 years

50-64 years

65 years and older

13. Have you ever had a pneumonia vaccine before?

Yes

Don’t Know

If yes, which type:

how many:

when:

“I have completed this form to the best of my knowledge. I have been given, read and understand the possible side effects

described in the Vaccine Information Statement (VIS) that could be caused by the vaccine(s). I give my consent for vaccines to

be administered as indicated. I agree to pay JCHD for any services not covered or paid by my insurance, and I understand that

JCHD may bill me for this amount.”

Signature:

Date:

(client or guardian must sign)

Nurse Reviewing Form:

Date:

Adult screening checklist 7/13/17 (bs)

Adult Screening Checklist For Contraindications To Vaccines - Jersey County Health Department

Related Articles

Related forms

Related Categories