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Screening Questionnaire and Consent Form for Adult Immunization

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For Patients: The following questions will help us determine which vaccines you may be given today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

I. Patient Information

Address

II. Vaccination Screening Questionnaire: (Please answer all questions)

1. Is the Person to Be Vaccinated Sick Today?
2. Do You Have Allergies to Medications, Food, a Vaccine Component or Latex?
3. Have You Ever Had a Serious Reaction After Receiving a Vaccination?
4. Do You Have a Long-Term Health Problem With Heart Disease, Lung Disease, Asthma, Kidney Disease, Metabolic Disease (e.g., Diabetes), a Blood Disorder, No Spleen, Complement Component Deficiency, a Cochlear Implant or a Spinal Fluid Leak? Are You on Long Term Aspirin Therapy?
5. Do You Have Cancer, Leukemia, HIV/Aids or Any Other Immune System Problem?
6. Do You Have a Parent, Brother or Sister With an Immune System Problem?
7. In the Past 3 Months, Have You Taken Medications That Affect Your Immune System, Such as Cortisone, Prednisone, Other Steroids, or Anticancer Drugs; Drugs for the Treatment of Rheumatoid Arthritis, Crohn’s Disease or Psoriasis; Or Have You Had Radiation Treatments?
8. Have You Had a Seizure, a Brain Disorder or Other Nervous System Problems (Such as Guillian-Barré Syndrome)?
9. During the Past Year, Have You Received a Transfusion of Blood or Blood Products or Been Given Immune (Gamma) Globulin or an Antiviral Drug?
10. For Women: Are You Pregnant or Is There a Chance You Could Become Pregnant During the Next Month?
11. Have You Received Any Vaccinations in the Past 4 Weeks?
Did You Bring Your Immunization Record Card With You?
It is important for you to have a personal record of your vaccinations. If you don’t have a personal record, ask your healthcare provider to give you one. Keep this record in a safe place and bring it with you every time you seek medical care. Make sure your healthcare provider records all your vaccinations on it.

III. Patient Consent

I have read, or have had read to me, the Vaccination Information Statement (VIS) regarding the vaccines(s) I am about to receive. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s). I consent to, or give consent for, the administration of the vaccine(s) and the notification of my primary care physician. I fully release and discharge their offices, directors and employees from any liability for illness, injury, loss or damage which may result there from. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment. I understand that I should remain in the pharmacy for 15 minutes for observation in case there is an adverse reaction.

IV. Immunizations Given Today

Vaccine Administration (Pharmacist Use ONLY)
Injection Site/Route
Vaccine Administration (Pharmacist Use ONLY)
Injection Site/Route
Vaccine Administration (Pharmacist Use ONLY)
Injection Site/Route
Did an Adverse Reaction Occur?
Contacted VAERS (https://vaers.hhs.gov/reportevent.html)
Time
:
Primary Medical Practitioner Contacted?
I hereby certify that I have verified the screening questionnaire and consent with the above named patient.

DID YOU?

  • Answer all of the client’s concerns and questions
  • Refer the client to for unavailable immunizations List:
  • Follow up with a call in 2 weeks for update on receiving immunization
  • Notify the client’s primary care medical practitioner of immunization within 72 hours of administration
  • Notify your state’s IIS registry of the immunization(s) if available
Information for Health Professionals about the Screening Questionnaire for Adults

Are you interested in knowing why we included a certain question on the Screening Questionnaire? If so, read the information below. If you want to find out even more, consult the references listed at the bottom of this page.

Note: For supporting documentation on the answers given below, go to the specific ACIP vaccine recommendation found at the following website: www.cdc.gov/vaccines/hcp/acip-recs/index.html.

  1. Are you sick today? [all vaccines]

There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events. However, as a precaution with moderate or severe acute illness, all vaccines should be delayed until the illness has improved. Mild illnesses (such as upper respiratory infections or diarrhea) are NOT contraindications to vaccination. Do not withhold vaccination if a person is taking antibiotics.

 2.  Do you have allergies to medications, food, a vaccine component or latex? [all vaccines]

An anaphylactic reaction to latex is a contraindication to vaccines that contain latex as a component or as part of the packaging (e.g., vial stoppers, prefilled syringe plungers, prefilled syringe caps). If a person has anaphylaxis after eating gelatin, do not administer vaccines containing gelatin. A local reaction to a prior vaccine dose or vaccine component, including latex, is not a contraindication to a subsequent dose or vaccine containing that component. For information on vaccines supplied in vials or syringes containing latex, see

www.cdc.gov/vaccines-pubs/pinkbook/downloads/appendices/B/latex-table.pdf; for an extensive list of vaccine components, see www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table- 2.pdf.

People with egg allergy of any severity can receive any IIV, RIV, or LAIV that is otherwise appropriate for the patient’s age and health status. The safety of LAIV in egg allergic people has not been established. For people with a history of severe allergic reaction to egg involving any symptom other than hives (e.g., angioedema, respiratory distress), or who required epinephrine or another emergency medical intervention, the vaccine should be administered in a medical setting, such as a clinic, health department, or physician office. Vaccine administration should be supervised by a healthcare provider who is able to recognize and manage severe allergic conditions.

3. Have you ever had a serious reaction after receiving a vaccination? [all vaccines]

History of anaphylactic reaction (see question 2) to a previous dose of vaccine or vaccine component is a contraindication for subsequent doses. Under normal circumstances, vaccines are deferred when a precaution is present. However, situations may arise when the benefit outweighs the risk (e.g., during a community pertussis outbreak).

4. Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on long term aspirin therapy? [MMR, VAR, LAIV[

A history of thrombocytopenia or thrombocytopenic purpura is a precaution to MMR vaccine. LAIV is not recommended for people with anatomic or functional asplenia, complement component deficiency, a cochlear implant, or CSF leak. These conditions, including asthma in adults, should be considered precautions for the use of LAIV. Aspirin use is a precaution to VAR.

5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? [LAIV, MMR, VAR, ZVL]

Live virus vaccines (e.g., LAIV, MMR, VAR, ZVL) are usually contraindicated in immunocompromised people. However, there are exceptions. For example, MMR vaccine is recommended and VAR vaccine should be considered for adults with CD4+ T-lymphocyte counts of greater than or equal to 200 cells/μL. Immunosuppressed people should not receive LAIV7.

6. Do you have a parent, brother, or sister with an immune system problem?
[MMR, VAR]

MMR or VAR vaccines should not be administered to persons who have a family history of congenital or hereditary immunodeficiency in first-degree relatives (i.e., parents and siblings), unless the immune competence of the potential vaccine recipient has been substantiated clinically or verified by a laboratory.

7. In the past 3 months, have you taken medications that affect your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments? [LAIV, MMR, VAR, ZVL]

Live virus vaccines (e.g., LAIV, MMR, VAR, ZVL) should be postponed until after chemotherapy or long-term high-dose steroid therapy has ended. For details and length of time to postpone, see references in Notes above.

Note: For summary information on contraindications and precautions to vaccines, go to the ACIP’s General Best Practice Guidelines for Immunization at: www.cdc.gov/vaccines/hcp/acip- recs/general-recs/contraindications.html

Some immune mediator and immune modulator drugs (especially the anti-tumor necrosis factor agents adalimumab, infliximab, etanercept, golimumab, and certolizumab pegol) may be immunosuppressive. A comprehensive list of immunosuppressive immune modulators is available in CDC Health Information for International Travel (the “Yellow Book”) available at wwwnc.cdc.gov/travel/yellowbook/2018/advising-travelers-with- specific-needs/immunocompromised-travelers. The use of live virus vaccines should be avoided in persons taking these drugs. To find specific vaccination schedules for stem cell transplant (bone marrow transplant) patients, see references in Notes above. LAIV can be given only to healthy non-pregnant people ages 2 through 49 years.

8. Have you had a seizure or a brain or other nervous system problem? [influenza, Td/Tdap]

Tdap is contraindicated in people who have a history of encephalopathy within 7 days following DTP/DTaP. An unstable progressive neurologic problem is a precaution to the use of Tdap. For people with stable neurologic disorders (including seizures) unrelated to vaccination, or for people with a family history of seizure, vaccinate as usual. A history of Guillain-Barré syndrome (GBS) is a consideration with the following: 1) Td/Tdap: if GBS has occurred within 6 weeks of a tetanus-toxoid vaccine and decision is made to continue vaccination, give Tdap instead of Td if no history of prior Tdap; 2) Influenza vaccine (IIV/LAIV): if GBS has within 6 weeks of a prior influenza vaccine, vaccinate with IIV if at high risk for severe influenza complications.

9. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? [MMR, VAR]

Certain live virus vaccines (e.g., MMR, VAR) may need to be deferred, depending on several variables. Consult General Best Practice Guidelines for Immunization (referenced in Notes above) for current information on intervals between antiviral drugs, immune globulin or blood product administration and live virus vaccines.

10. For women: Are you pregnant or is there a chance you could become pregnant during the next month? [HPV,IPV, MMR, LAIV, VAR, ZVL]

Live virus vaccines (e.g., MMR, VAR, ZVL, LAIV) are contraindicated one month before and during pregnancy because of the theoretical risk of virus transmission to the fetus. Sexually active women in their childbearing years who receive live virus vaccines should be instructed to avoid pregnancy for one month following receipt of the vaccine. On theoretical grounds, Inactivated Poliovirus Vaccine (IPV) should not be given during pregnancy; however, it may be given if risk of exposure is imminent and immediate protection is needed (e.g., travel to endemic areas). Inactivated influenza vaccine and Tdap are both recommended during pregnancy but the preferred time for Tdap administration is 27-36 weeks’ gestation. HPV vaccine is not recommended during pregnancy.

11. Have you received any vaccinations in the past 4 weeks?
[LAIV, MMR, VAR, yellow fever, ZVL]

People who were given either LAIV or an injectable live virus vaccine (e.g., MMR, VAR, ZVL, yellow fever) should wait 28 days before receiving another vaccination of this type (30 days for yellow fever). Inactivated vaccines may be given at any spacing interval if they are not administered simultaneously.

Vaccine Abbreviations:

  • LAIV = Live attenuated influenza vaccine
  • HPV = Human papillomavirus vaccine
  • IIV = Inactivated influenza vaccine
  • IPV = Inactivated poliovirus vaccine
  • MMR = Measles, mumps, and rubella vaccine
  • RIV = Recombinant influenza vaccine
  • Td/Tdap = Tetanus, diphtheria, (acellular pertussis) vaccine
  • VAR = Varicella vaccine
  • ZVL = Zoster vaccine live