Senior Care Vaccination Assessment Form
Complete this form to assess vaccination readiness and history for seniors in care settings.
Senior's current care setting
*
Nursing home
Assisted living facility
Home care
Independent living
Other
Age group of the senior
*
Under 65
65–74
75–84
85 and above
Has the senior received any vaccinations in the past 12 months?
*
Yes
No
Not sure
Please indicate which vaccines the senior has received in the past 12 months
Influenza (flu)
COVID-19
Pneumococcal
Shingles
None of the above
Other
How would you rate the senior's overall willingness to receive recommended vaccinations?
*
1
2
3
4
5
Please indicate your level of agreement with the following statements
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Vaccinations are important for the senior's health
1
2
3
4
5
The senior has easy access to vaccination services
6
7
8
9
10
There are concerns about vaccine side effects
11
12
13
14
15
Has the senior experienced any side effects from vaccinations in the past?
Yes
No
Not sure
Are there any known medical reasons preventing the senior from receiving certain vaccines?
Yes
No
Not sure
What are the main challenges or barriers to vaccination for the senior?
Transportation or mobility issues
Lack of information
Concerns about side effects
Difficulty scheduling appointments
None
Other
Please describe any additional concerns or comments regarding vaccination planning for the senior
Submit Assessment
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