Pre-Vaccination Check List for COVID-19 Vaccines

For vaccine recipients:

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.

QuestionYesNo Don't Know
1. Are you feeling sick today?

2. Have you ever recieved a dose of COVID-19 vaccine?

           *If yes, which product?
______ Pfizer
______ Moderna
Another product ____________________________
3. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something?
For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital?

           *Was the severe allergic reaction after receiving a COVID-19 vaccine?

           *Was the severe allergic reaction after receiving another vaccine or another injectable                  medication?

4. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?

5. Have you received another vaccine in the last 14 days?

6. Have you had positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?

8. Do you have a bleeding disorder or are you taking a blood thinner?

9. Are you pregnant or breastfeeding?