Flu Vaccine Screening Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
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
What is your job?
Where do you work?
Have you been exposed to someone diagnosed with COVID-19 in the past 14 days?
Yes
No
Are you living with someone who was diagnosed with COVID-19?
Yes
No
Have you been exposed to someone with a suspected COVID-19 because the result is still pending?
Yes
No
Are you living with someone who was suspected to have COVID-19 because the result is still pending?
Yes
No
Have you been exposed to someone who has COVID-19 symptoms?
Yes
No
Are you currently sick?
Yes
No
If yes, what are you currently experiencing?
Are you pregnant?
Yes
No
Do you have allergies? If yes, please provide what type of allergy and what causes it.
Did you receive a flu vaccine before?
Yes
No
Did you have any threatening reaction in the past when you receive a flu vaccine?
Yes
No
Do you have Guillain-Barre syndrome?
Yes
No
Do you have a long-term health problem? (like heart, lung, kidney problems, etc.)
Yes
No
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: