Vaccination Form

Vaccination Questionnaire

First Name

Date Of Birth

NHS Number

Parent / Guardian Name

Address

Address Line 1

Address Line 2

City

Zip Code

Vaccination Questions

1. Which type of vaccination appointment are you requesting?

NHS seasonal vaccination

Private or travel vaccination

Not sure

2. Are you currently unwell or experiencing any of the following?

High fever

Mild or moderate fever

Current infection or taking antibiotics

Vomiting or diarrhoea

COVID-19 or flu-like symptoms

More than one of these

None of these

3. Please state which vaccine or vaccines you are requesting.

4. Have you ever had a serious reaction after a vaccine?

Yes

Not sure

I have not had a vaccine before

0 means you have no pain; 1-3 means mild pain; 4-7 moderate pain; 8-10 severe pain

5. Are you allergic to any vaccine, vaccine ingredient, latex or medicine?

Yes

Not sure

6. Have you ever fainted or felt faint during an injection or vaccination?

Yes

7. Please list any medical conditions and all medicines, including blood thinners, immune-suppressing medicines, herbal remedies and supplements.

8. Are you pregnant, trying to become pregnant or breastfeeding?

Yes

9. If yes, please provide details.

10. Are your routine vaccinations up to date?

Yes

Not sure

11. Do you have any allergies?

Yes

12. Please list any allergies and describe the reaction.

13. Please tell us the best times to contact you.

Consent

15. Are you able to come into the Pharmacy for an appointment?

I confirm the information provided is accurate.

I do consent to assessment and GP notification where appropriate.

I understand this questionnaire must be reviewed before my appointment request can be accepted.

Vaccination Questionnaire

Vaccination Questions

Consent

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