COVID-19 Vaccination Screening Questionnaire
Please complete this form to help determine your eligibility and safety for receiving the COVID-19 vaccine.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Have you had a fever, cough, or other symptoms of illness in the past 14 days?
*
Yes
No
Have you tested positive for COVID-19 in the past 90 days?
*
Yes
No
Have you received any COVID-19 vaccine dose before?
*
Yes
No
Do you have any allergies to medications, food, or vaccines?
*
Yes
No
Are you currently taking any medications or have any chronic health conditions? If yes, please specify.
Have you ever had a severe allergic reaction (anaphylaxis) to any substance?
*
Yes
No
Are you currently pregnant, planning to become pregnant, or breastfeeding?
Yes
No
Not applicable
Submit Screening Questionnaire
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