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Vaccination
Vaccination
Conrad Hake
2021-01-30T09:17:44-06:00
Patient Demographic Information
Last Name
*
First Name
*
Middle Initial
Date of Birth
*
Date Format: MM slash DD slash YYYY
Sex
*
Male
Female
Transgender
Other
Race
*
White
Black
Asian
Pacific Islander
American Indian/Alaskan Native
None Specified
Refused
Hispanic Ethnicity
*
Yes
No
Unknown
Refused
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Mobile Phone
required if requesting text notifications
Email
Would like a reminder for the next appointment
*
Yes
No
Receive reminder as:
Call
Text
Email
Insurance Type
*
Private or Employer Insurance
Underinsured
Uninsured
Medicaid
Medicare
Please Upload Insurance
jpg, gif, png, or pdf files accepted.
Accepted file types: jpg, gif, png, pdf.
Health History
1. Are you feeling sick today?
*
Yes
No
Unknown
2. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or Epi Pen or for which you had to go to the hospital?
*
Yes
No
Unknown
3. Have you ever had a serious reaction after any vaccination or injectable medication including a previous dose of the COVID-19 vaccine?
*
Yes
No
Unknown
4. In the past 14 days have you had contact with a confirmed COVID-19 patient?
*
Yes
No
Unknown
5. Are you breastfeeding or pregnant?
*
Yes
No
Unknown
6. Have you received passive antibody therapy as a treatment for COVID-19?
*
Yes
No
Unknown
7. Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS or other immune system problems or taking medication that affects your immune system)
*
Yes
No
Unknown
8. Do you have a bleeding disorder or are you taking a blood thinner?
*
Yes
No
Unknown
9. Have you ever received a dose of COVID-19 vaccine?
*
Yes
No
Unknown
How many vaccines Have you received?
*
One
Two
What type of Vaccine?
*
Pfizer
Moderna
Date of First Vaccine?
*
Date Format: MM slash DD slash YYYY
Date of Second Vaccine?
*
Date Format: MM slash DD slash YYYY
10. Have you received any vaccination within the last 14 days?
*
Yes
No
Unknown
Date of First Vaccine?
*
Date Format: MM slash DD slash YYYY
What type of Vaccine?
*
Pfizer
Moderna
Please list any health issues that may put you in a higher risk category.
Such as hypertension, diabetes, other autoimmune, BMI >40
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