COVID-19 Vaccination Screening Form
Name
First Name
Last Name
Age
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Marital Status
Company/Employer
Position/Title
Health Insurance #
Is this your first dose or second dose?
First dose
Second dose
If this is your second dose, when is the first one?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any of the following symptoms below?
Fever
Dry cough
Tiredness
Aches and pains
Sore throat
Diarrhoea
Conjunctivitis
Headache
Loss of taste or smell
Rash on skin
Difficulty breathing
Chest pain or pressure
Loss of speech or movement
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Are you taking steroids?
Yes
No
Are you undergoing chemotherapy?
Yes
No
Do you have any bleeding disorder?
Yes
No
Do you have cancer, HIV/AIDS, or any autoimmune disease?
Yes
No
Are you currently taking medications that can affect your immune system?
Yes
No
Do you have any allergies to food?
Yes
No
Do you have any allergies to any vaccine?
Yes
No
Do you have allergies to polyethylene glycol (PEG)?
Yes
No
Acknowledgment
I have read the COVID-19 information sheet.
I understand that this vaccine requires 2 doses.
I understand the risks and benefits of the vaccine.
Information gathered from this form will be strictly confidential. This data is collected so that it can be used for the good of the patient in terms of handling them and protecting them.
Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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