Patient Name

First Name Last Name

Age

1. Are you feeling sick today?

Yes No Don't know

2. Have you ever received a dose of COVID-19 vaccine?

Yes No Don't know

Which vaccine product did you receive?

Pfizer Moderna Another product

3. Have you ever had an allergic reaction to:

(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing)

A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures:

Yes No Don't know

Polysorbate:

Yes No Don't know

A previous dose of COVID-19 vaccine:

Yes No Don't know

4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?

Yes No Don't know

This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.

Yes No Don't know

6. Have you received any vaccine in the last 14 days?

Yes No Don't know

7. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

Yes No Don't know

8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

Yes No Don't know

9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

Yes No Don't know

10. Do you have a bleeding disorder or are you taking a blood thinner?

Yes No Don't know

11. Are you pregnant or breastfeeding?

Yes No Don't know

Form reviewed by

Date

Prevaccination Checklist for COVID-19 Vaccines