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Precision LTC Covid Forms

COVID-19 Immunization Screening and Consent Form






Street Address
City
State
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(The vaccines are provided free of charge regardless of insurance coverage and you will not be billed)


Screening Questionnaire
1. Will you be under the age of 12 years old for the Pfizer vaccine, or under 18 years old for theModerna vaccine, on the day of your appointment?
2. Are you feeling sick today?
3. In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?
4. Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90days (3 months)? If yes, when did you receive the last dose? Date:
5. Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing,anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything?
6. Are you pregnant or considering becoming pregnant?
7. Do you have a bleeding disorder, a history of blood clost or are you taking a blood thinner?
8. Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart?
9. Do you have cancer, leukemia, HIV/AIDS or any other condition that weakens the immune system?
10. Are you 50 through 64 years old AND have one or more of the following conditions(due to increased risk of moderate or severe illness or death from the virus that causes COVID-19):
1.) Cancer (current or in remission, including 9/11-related cancers); 2.)Chronic kidney disease; 3.) Pulmonary Disease, including but not limited to, COPD(chronic obstructive pulmonary disease), asthma (moderate -tosevere), pulmonaryfibrosis, cystic fibrosis, and 9/11 related pulmonary diseases; 4.) Intellectual andDevelopmental Disabilities including Down Syndrome; 5.) Heart conditions, includingbut not limited to heart failure, coronary artery disease, cardiomyopathies, orhypertension (high blood pressure); 6.) Immunocompromised state (weakened immunesystem) including but not limited to solid organ transplant or from blood or bonemarrow transplant, immune deficiencies, HIV, use of corticosteroids, use of otherimmune weakening medicines, or other causes; 7.) Severe Obesity (BMI 40 kg/m2 orhigher), Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2),Overweight (BMI of 25 kg/m2 or higher but < 30kg/m2); 8.) Pregnant; 9.) Sickle celldisease or Thalassemia; 10.) Type 1 or 2 diabetes mellitus; 11.) Cerebrovascular disease(affects blood vessels and blood supply to the brain); 12.) Neurologic conditionsincluding but not limited to Alzheimer's Disease or dementia; 13.) Liver disease; 14.)Current or former smoker; 15.) Substance use disorder.
11. Are you 18 through 49 years old AND have one or more of the underlyingmedical conditions listed above, and are seeking a booster because the benefitsoutweigh the risks?
12. Are you 18 through 64 years old AND are at increased risk for COVID-19exposure and transmission because of occupational or institutional setting?
13. Have you received 2 doses of the Pfizer or Moderna vaccine, the second dose being atleast 6 months ago?
Date of 2nd Dose:
14. Have you received a previous dose of Janssen COVID-19 vaccine?
Date received (if applicable):


The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks.