| 1.Are you sick today? | | | |
| 2.Have you tested positive for COVID-19 in the last 3 months? | | | |
3.Have you ever had an allergic reaction to any medication (injectable, pill, liquid), vaccine, food, or latex? (This includes rash, problems breathing, swelling, use of epinephrine or a hospital visit.) | | | |
| 4.Do you or a family member have a weakened immune system due to HIV/AIDS, cancer, leukemia or any other condition or are you taking immunosuppressive treatments like steroids or anti-cancer drugs? | | | |
| 5.Has the patient had a history of Guillain Barré Syndrome? | | | |
| 6.Has the patient had a health problem with lung, heart, kidney, liver, diabetes, asthmas, or a blood disorder? Is he/she on long-term aspirin therapy? | | | |
| 7.In the past three months, has the patient taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis, or had radiation treatments? | | | |
| 8.In the past year, has the patient received a transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug? | | | |
| 9.Has the patient had any vaccines in the past 4 weeks? | | | |
| 10.Does the patient use tobacco products? | | | |
| 11.Is the patient pregnant or is there a chance of becoming pregnant in the next 3 months? | | | |
COVID-19 Assessment – Only continue this section if planning on getting a COVID-19 Vaccine |
| | Yes | No | Don't Know |
| 1.Have you ever received a dose of COVID-19 vaccine? | | | |
| If yes, which product(s) did you receive? Pfizer Moderna J&J Other | | | |
| 2.Have you ever had an allergic reaction to a component of the COVID-19 vaccine, such as polyethylene glycol (PEG), polysorbate, or a previous dose of COVID-19? | | | |
| 3.Have you ever fainted after a blood draw or vaccination? | | | |
| 4.Are you a male between the ages of 12 and 39 years old? | | | |
| 5.Do you have a history of myocarditis or pericarditis (heart inflammation)? | | | |
| 6.Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)? | | | |
| 7.Have you received a blood cell transplant or CAR-T-cell therapies since receiving COVID-19 vaccine? | | | |
Only If you plan on receiving an intranasal flu dose today continue with this section. This would be two spritzes, one up each nostril that would cover you as your flu dose for the season. |
Intranasal Flu |
| | Yes | No | Don't Know |
| 1.Is the person to be vaccinated younger than 2 years or older than 49 years? | | | |
| 2.Have you had wheezing or asthma in the past 12 months? | | | |
| 3.Do you have a long-term health problem with heart disease, lung disease (including asthma), kidney disease, neurologic disease, liver disease, or metabolic disease (e.g., diabetes)? | | | |
| 4.Do you have a) an open channel between the cerebrospinal fluid (CSF) and the mouth, throat, nose or ear or any other cranial CSF leak, or b) a cochlear implant? | | | |
| 5.Are you currently taking influenza antiviral medications, or have you taken any within the past 3 weeks? | | | |
| 6.Is the person to be vaccinated a child or teen age 6 months through 17 years and receiving aspirin or salicylate-containing medicine? | | | |
| 7.Are you currently pregnant or could become pregnant within the next month? | | | |
| 8.Do you live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)? | | | |
| 9.Have you received any vaccines in the last 28 days? | | | |
If my insurance does not cover the vaccine or administration fee, I understand I am responsible for all co-pays, deductibles, and uncovered/exhausted benefits. |