COVID-19 Vaccination Form

Have you had an allergic reaction to a previous dose of a COVID-19 vaccine?*YesNo

Have you had anaphylaxis to another vaccine or medication?*YesNo

Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine?*YesNo

Do you have a mast cell disorder?*YesNo

Have you had COVID-19 before?*YesNo

Do you have a bleeding disorder?*YesNo

Do you take any medicine to thin your blood (an anticoagulant therapy)?*YesNo

Do you have a weakened immune system (immunocompromised)?*YesNo

Are you pregnant?*YesNo

Have you been sick with a cough, sore throat, fever or are feeling sick in another way?*YesNo

Have you had a COVID-19 vaccination before?*YesNo

Have you received any other vaccination in the last 7 days?*YesNo

Have you ever been diagnosed with capillary leak syndrome?YesNo

Have you ever had major venous and/or arterial thrombosis in combination with thrombocytopenia, including diagnosed Thrombotic Thrombocytopenic Syndrome (TTS), following a previous dose of a COVID-19 vaccine?YesNo

Have you ever had cerebral venous sinus thrombosis?YesNo

Have you ever had heparin-induced thrombocytopenia?YesNo

Have you ever had blood clots in the abdominal veins (splanchnic veins)?YesNo

Have you ever had antiphospholipid syndrome associated with blood clots?YesNo

Are you under 60 years of age?YesNo

Have you been diagnosed with myocarditis and/or pericarditis that is attributed to a previous dose of Pfizer or Moderna?YesNo

Have you had myocarditis, pericarditis or endocarditis within the past six months?YesNo

Do you currently have acute rheumatic fever or acute rheumatic heart disease?YesNo

Do you have severe heart failure?YesNo

Pharmacist name

Pharmacist name

I am the patient’s legal guardian or substitute decision maker, and agree to COVID-19 vaccination of the patient named above

Guardian/substitute