Tetanus/Diphtheria/Pertussis Screening Checklist
Patient Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Phone Number:
*
Email Address:
Screening Checklist for Contraindications to Vaccines for Adults
DOB:
Date:
/
Month
/
Day
Year
Date
Date:
/
Month
/
Day
Year
Date
Patient Name:
DOB:
Date:
/
Month
/
Day
Year
Date
Please answer the following questions to help us determine your eligibility.
*
Yes
No
Don't Know
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 weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, 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?
Primary Care Provider?
We will inform this doctor or practitioner that you received a vaccine at our pharmacy.
This Form Was Completed By:
*
Please review the follow Tdap Vaccine Information Sheet.
Signature:
*
Submit
Should be Empty: