| 1.Are you sick today? | | | |
| 2.Has the child tested positive for COVID-19 in the last 3 months? | | | |
3.Has the child 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.Does the child or a family member have a weakened immune system due to HIV/AIDS, cancer, leukemia or any other condition or are they taking
immunosuppressive treatments like steroids or anti-cancer drugs? | | | |
| 5.For Babies: Have you ever been told that the baby had intussusception? | | | |
| 6.Has the child, a sibling, or a parent had a seizure; has the child had a brain or other nervous system problem? | | | |
| 7.Has the child had a history of Guillain Barré Syndrome? | | | |
| 8.Has the child had a health problem with lung, heart, kidney, liver, diabetes, asthmas, or a blood disorder? Is the child on long-term aspirin therapy? | | | |
| 9.In the past three months, has the child 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? | | | |
| 10.In the past year, has the child received a transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug? | | | |
| 11.Has the child had any vaccines in the past 4 weeks? | | | |
| 12.Does the child/teen use tobacco products? | | | |
| 13.Is the child/teen pregnant? | | | |
COVID-19 Assessment – Only continue this section if planning on getting a COVID-19 Vaccine |
| | Yes | No | Don't Know |
| 1.Has the child ever received a dose of COVID-19 vaccine? | | | |
| If yes, which product(s) did you receive? Pfizer Moderna | | | |
| 2.Has the child 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.Has the child ever fainted after a blood draw or vaccination? | | | |
| 4.Is the child a male between the ages of 12 and 18 years old? | | | |
| 5.Has child had a history of myocarditis or pericarditis (heart inflammation)? | | | |
| 6.Does the child have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)? | | | |
| 7.Has child 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 old? | | | |
| 2.Has child had wheezing or asthma in the past 12 months? | | | |
| 3.Has child had 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.Does the child 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.Is the child currently taking influenza antiviral medications, or have you taken any within the past 3 weeks? | | | |
| 6.Is the child to be vaccinated age 6 months through 17 years and receiving aspirin or salicylate-containing medicine? | | | |
| 7.Is the child/teen currently pregnant? | | | |
| 8.Does child 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 they 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. |