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Patient Information

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1. Have you recently been experiencing any COVID-19 symptoms?
Symptoms:
2. Have you been diagnosed with COVID-19 in the past?
3. Have you recently been exposed to someone who is a probable or confirmed COVID-19 case?
4. Have you recently returned from overseas travel?
5. Need for travel abroad?
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Are you currently pregnant
Do you have allergies to medications, food, a vaccine component, or latex?
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?
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
Have you had a seizure or a brain or other nervous system problem?
Are you sick today?
Have you ever had a serious reaction after receiving a vaccination?
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?
Do you have a parent, brother, or sister with an immune system problem?
For women: Are you pregnant or is there a chance you could become pregnant during the next month?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
Have you received any vaccinations in the past 4 weeks?
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