Sample Questionnaire on Immunization Form

Immunization Screening Questionnaire Client Name Print Date of Birth Address City Zip Code Phone Number For Clients/Parents/Guardians The following questions will help us determine which vaccines may be given today. If a question is not clear please ask the healthcare provider to explain it. YES NO 1. Have you had a fever or been sick recently 2. Do you have allergies to medications food a vaccine component or latex 3. Have you ever had a serious reaction after receiving a vaccination 4. Immunization Screening Questionnaire Client Name Print Date of Birth Address City Zip Code Phone Number For Clients/Parents/Guardians The following questions will help us determine which vaccines may be given today. If a question is not clear please ask the healthcare provider to explain it. YES NO 1. Have you had a fever or been sick recently 2. Do you have allergies to medications food a vaccine component or latex 3. Have you ever had a serious reaction after receiving a vaccination 4. Have you fainted or nearly fainted during or after vaccination 6. Do you have cancer leukemia AIDS or any other immune system problem 7. In the past 3 months have you taken cortisone other steroids or anticancer drugs or have you had x-ray treatments 8. Do you have a long-term health problem with heart disease lung disease asthma kidney disease metabolic disease e*g* diabetes anemia or other blood disorder 9. During the past year have you received a transfusion of blood or blood products or been given immune gamma globulin or an antiviral drug 10. Have you had the Thymus gland removed or a history of Thymus problems Myasthenia Gravis DiGeorge syndrome or Thyroma 11. Have you received any vaccinations in the past 4 weeks in the next month 13. for Women Are you pregnant or is there a chance you could become pregnant during the next month Signature Form Reviewed By RN 11/14 Date. Immunization Screening Questionnaire Client Name Print Date of Birth Address City Zip Code Phone Number For Clients/Parents/Guardians The following questions will help us determine which vaccines may be given today. If a question is not clear please ask the healthcare provider to explain it. YES NO 1. Have you had a fever or been sick recently 2. If a question is not clear please ask the healthcare provider to explain it. YES NO 1. Have you had a fever or been sick recently 2. Do you have allergies to medications food a vaccine component or latex 3. Have you ever had a serious reaction after receiving a vaccination 4. Do you have allergies to medications food a vaccine component or latex 3. Have you ever had a serious reaction after receiving a vaccination 4. Have you fainted or nearly fainted during or after vaccination 6. Do you have cancer leukemia AIDS or any other immune system problem 7. Have you fainted or nearly fainted during or after vaccination 6. Do you have cancer leukemia AIDS or any other immune system problem 7. In the past 3 months have you taken cortisone other steroids or anticancer drugs or have you had x-ray treatments 8.