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First Name *

Last Name *

Phone Number *

Email Address *

D.O.B *

Vaccine Type *

1. Are you feeling sick today? *YesNo

2. Do you have allergies to medications, food, a vaccine component, or latex? *YesNoDon't Know

If yes, Please List *

3. Have you ever had a serious reaction after receiving a vaccine? *YesNoDon't Know

If yes, Please List *

4. Do you have any of the following: a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy? *YesNoDon't Know

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? *YesNoDon't Know

6. Do you have a parent, brother, or sister with an immune system problem? *YesNoDon't Know

7. In the past 6 months, have you taken medications that affect your 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 radiation treatments? *YesNoDon't Know

8. Have you had a seizure or a brain or other nervous system problem? *YesNoDon't Know

9. In the past year, have you received immune (gamma) globulin, blood/blood products, or an antiviral drug? *YesNoDon't Know

10. Are you pregnant? *YesNoDon't Know

11. Have you received any vaccinations in the past 4 weeks? *YesNoDon't Know

12. Have you ever felt dizzy or faint before, during, or after a shot? *YesNoDon't Know

13. Are you anxious about getting a shot today? *YesNoDon't Know

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Book an appointment | Melcon's Pharmacy

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Book an appointment | Melcon's Pharmacy

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