Student Name
Student Date of Birth

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Please answer questions about the person receiving the vaccine(s)

The following questions will help us determine which vaccines your student may be given. If you answer yes to any question, it does not necessarily mean they should not be vaccinated. It means additional questions must be asked. If a question is not clear, please call 816-595-4355.

  1.     Yes    No
    Do you have allergies to medications, food, a vaccine component, or latex?
    If Yes, what is your student allergic to?   

  2. Have you had a serious reaction to a vaccine in the past?
        Yes    No

  3. Do you have a health problem with lung, heart, kidney, or metabolic disease, i.e., diabetes, asthma, or a blood disorder? Are you on long term aspirin therapy?
        Yes    No

    If Yes, please explain:   

  4. Have you ever had a seizure, or had a brain or other nervous system problem?
        Yes    No

  5. Do you have or live with someone who has cancer, leukemia, HIV/AIDS, or immune system problems?
        Yes    No

  6. In the past 3 months, have you taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or had radiation treatments?
        Yes    No

  7. In the past year, have you received a blood transfusion or blood products, or have been given a medicine called immune (gamma) globulin or an antiviral drug?
        Yes    No

  8. Have you received any vaccinations in the past 4 weeks?
        Yes    No

  9. Did you bring your immunization record with you?
        Yes    No

    Additional Questions for Females Only:
  10. Are you nursing, pregnant, or is there a chance you could become pregnant during the next month?
        Yes    No

    If pregnant, how many weeks?   

  11. Are you currently using a birth control method?
        Yes    No

  12. To be answered the day of clinic: Are you sick today?
        Yes    No

Form completed by   
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