Vaccination Contraindications Checklist

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Personal Info

Name*
Date of Birth*

Checklist

Are you sick today?*
Do you have allergies to medications, food, a vaccine component, or latex?*
Have you ever had a serious reaction after receiving a vaccination?*
Do you have a long-term problem in heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you a long-term aspirin therapy?*
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
Do you have a parent, brother, or sister with an immune system problem?*
In the past 3 months, have you taken medications that affect you immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had a radiation treatments?*
Have you had a seizure or a brain or other nervous system problem?*
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*
For women: Are you a pregnant or is there a chance you could become pregnant during the next month?
Have you received any vaccinations in the past 4 weeks?*
Did you bring your immunization record card with you?*

COVID-19 Self Checklist

Do you have a fever (temp over 37.9 °C) without having taken fever medication?*
Please check if you have any of the following:
Have you experienced any gastro-intestinal symptoms such as nausea/vomiting, diarrhea, loss of appetite?*
Have you, or anyone you have been close contact with, been diagnosed with COVID-19, or been placed on quarantined for possible contact with COVID-19?*
Have you been asked to self-isolate or quarantine by a medical professional or a local public health official?*
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Form completed on: 01/27/2026

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