01/05/2021
CS321629-E
1
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.
I understand that Hawaii Pacific Health may bill my insurance for vaccine administration.
Adapted with appreciation from the Immunization Action Coalition (IAC) screening checklists
Patient Name
Age
Yes No
Don't
know
Form reviewed by Date
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 vaccine?
• If yes, which vaccine product did you receive?
Pzer Moderna Another product
3. Have you ever had an allergic reaction to:
(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital.
It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
• A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in
some medications, such as laxatives and preparations for colonoscopy procedures
• Polysorbate
• A previous dose of COVID-19 vaccine
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an
injectable medication?
(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that
caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives,
swelling, or respiratory distress, including wheezing.)
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a
component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would
include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as
treatment for COVID-19?
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do
you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
Prevaccination Checklist
for COVID-19 Vaccines
