• Prevaccination Checklist for COVID-19 Vaccines

    The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
  • 1. Are you feeling sick today?
  • 2. Have you ever received a dose of COVID-19 vaccine?
  • Which vaccine product did you receive?

  • 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:
  • Polysorbate:
  • A previous dose of COVID-19 vaccine:
  • 4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?

  • 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.
  • 6. Have you received any vaccine in the last 14 days?
  • 7. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
  • 8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
  • 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?
  • 10. Do you have a bleeding disorder or are you taking a blood thinner?
  • 11. Are you pregnant or breastfeeding?
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