Screening Checklist For Contraindications To Vaccines For Adults


Screening Checklist
patient name
for Contraindications
date of birth
to Vaccines for Adults
For patients: The following questions will help us 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 your healthcare provider to explain it.
1. Are you sick today?
2. Do you have allergies to medications, food, a vaccine component, or latex?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have a long-term health problem with heart disease, lung disease, asthma,
kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?
5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
6. In the past 3 months, have you taken medications that affect your immune system,
such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of
rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?
7. Have you had a seizure or a brain or other nervous system problem?
8. During the past year, have you received a transfusion of blood or blood products,
or been given immune (gamma) globulin or an antiviral drug?
9. For women: Are you pregnant or is there a chance you could become pregnant
during the next month?
10. Have you received any vaccinations in the past 4 weeks?
form completed by
form reviewed by
Did you bring your immunization record card with you?
It is important for you to have a personal record of your vaccinations. If you don’t have a personal record,
ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every time
you seek medical care. Make sure your healthcare provider records all your vaccinations on it.
Technical content reviewed by the Centers for Disease Control and Prevention
651 - 647 - 9009
Saint Paul, Minnesota
Item #P4065 (10/16)


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