COVID Vaccine Screening – Forward Pharmacy

Screening Questionnaire for Immunization

Name*

First Last

Email*

Are you sick today? (Fever, cough, shortness of breath, nausea/vomiting in the last 24 hours)*

Have you received antibody therapy or convalescent plasma for COVID treatment in the past 90 days?*

Have you received a vaccine in the past 14 days?*

Which vaccines? Please list the name and dates, along with any other information.*

Are you currently in your isolation or quarantine period due to COVID-19?*

Have you received a dose of the COVID vaccine?*

Which brand of vaccine?*

Which date did you receive vaccine?*