Prevaccination Checklist for COVID-19 Vaccines

Patient Name

First NameLast Name

Age

1. Are you feeling sick today?

YesNoDon't know

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

YesNoDon't know

Which vaccine product did you receive?

PfizerModernaAnother 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:

YesNoDon't know

Polysorbate:

YesNoDon't know

A previous dose of COVID-19 vaccine:

YesNoDon't know

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

YesNoDon'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.

YesNoDon't know

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

YesNoDon'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?

YesNoDon't know

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

YesNoDon'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?

YesNoDon't know

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

YesNoDon't know

11. Are you pregnant or breastfeeding?

YesNoDon't know

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