Lopez Island Pharmacy Vaccination Questionnaire Ver1.2 rev 06/02/2020

Lopez Island Pharmacy (360) 468-2616 Fax (360) 468-3825

Vaccination Consent Form

rev:06/04/2020 HIPAA Compliant ver 1.3

Patient Name (Who is receiving the vaccination)*

First NameMiddle NameLast NameSuffix

Birth Date:*

Date

Sex*

MaleFemale

Vaccine to receive?

Influenza Vaccine is NOT available until the Fall of 2020

**** PLEASE MAKE ANOTHER SELECTION ****

Is Lopez Island Medical Center your "Primary Provider"?

YesNo

Primary Care Provider and Office Phone

Lopez Island Medical Center
360-468-2245
PLEASE CONTINUE

Then please enter your "Primary Care" provider name and phone number.

Enter your Primary Care provide and phone number.

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 today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.

1. Are you sick today? If unsure speak to the Pharmacist now.*

YesNoDon't Know

If "Yes" to #1 please describe

Please describe why you answered YES

If "Don't Know" to #1 please describe.

Please describe why you answered Don't Know

2. Do you have any allergies to Medications, Food, Latex or a vaccine component?*

YesNoDon't Know

If "Yes" to #2 please describe.

Describe your allergy?

If "Don't Know" to #2 please describe.

Please describe why you answered Don't Know

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

YesNoDon't Know

If "Yes" to #3 please describe.

Please describe what happened

If "Don't Know" to #3 please describe.

Please describe why you answered Don't Know

4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease(diabetes), anemia or other blood disorders?*

YesNoDon't Know

If "Yes" to #4 please describe.

Describe your long-term health problems

If "Don't Know" to #4 please describe.