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Vaccine Checklist
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For vaccine recipients: The following questions will help 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.
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Are you feeling sick today?
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Have you ever received a dose of COVID-19 vaccine?
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If yes, which vaccine product did you receive?
Have you ever had an allergic reaction to:
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(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.)
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A component of a COVID-19 vaccine including either of the following:
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Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
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Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids
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A previous dose of COVID-19 vaccine
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A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction?
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Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
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(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.)
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Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.
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Have you received any vaccine in the last 14 days?
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Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
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Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
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Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
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Do you have a bleeding disorder or are you taking a blood thinner?
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Are you pregnant or breastfeeding?
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Do you have dermal fillers?
