Vaccination Questionnaire

Full Name *

Please tick the answers below, sign and submit.

*

I have not had myocarditis, pericarditis or serious systemic allergic reaction to any drug or to any vaccine including a previous dose of COVID-19 vaccine Astrazeneca/Pfizer/Moderna

*

I am not currently unwell with an acute fever (the presence of a minor infection is not a contraindication for vaccination).

*

I have not received shingles vaccination in the last seven days.

*

I have never had an unexplained anaphylaxis reaction.

*

I have never experienced an urticarial (itchy) skin reaction following a COVID-19 vaccine.

*

I do not have any history of blood or bleeding disorders (such as capillary leak syndrome, idiopathic thrombocytopenia)

11. Are you on anticoagulants (Blood Thinners)? *

Yes

No

Please make you vaccinator aware of this at the appointment.

Signature *

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