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Friday Harbor Drug
210 Spring St
Friday Harbor, WA 98250
360-378-4421
contact@fridayharbordrug.com
COVID-19 Vaccine Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Race
*
...
Caucasian
African American
Hispanic
Asian
American Indian
Pacific Islander
Other
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
Primary Care Provider
Driver's License or Social Security Number
*
Medicare Number (if applicable)
The following questions will help determine which vaccine may be given in the pharmacy. Please answer these questions for the person receiving the vaccine today. If the question is not clear, please ask the pharmacist to explain it.
1. Have you received a vaccine before (flu, shingles, pneumonia, etc.)?
*
...
Yes
No
2. Have you received any other vaccine in the past 14 days?
*
...
Yes
No
3. Have you received a dose of COVID-19 vaccine?
*
...
Yes
No
---3a. If yes, select the one you received:
...
Moderna
Pfizer
Johnson & Johnson
---3b. If yes, on what date did you receive the COVID-19 vaccine?
MM
DD
YYYY
4. Have you previously had COVID-19
*
...
Yes
No
---4a. If yes, when were you diagnosed?
MM
DD
YYYY
5. Did you receive antibody treatment (monoclonal antibody or convalescent plasma) for a COVID-19 infection?
*
...
Yes
No
---5a. If yes, when did you receive this treatment?
MM
DD
YYYY
6. Are you allergic to polyethylene glycol (PEG) or polysorbate?
*
...
Yes
No
7. Have you ever had a severe allergic reaction that required immediate medical attention or use of epinephrine (epi-pen)?
*
...
Yes
No
8. Have you had a severe adverse reaction to any vaccine in the past?
*
...
Yes
No
---8a. If yes, what was your reaction?
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
*
...
Yes
No
10. Are you pregnant or breastfeeding?
*
...
Yes
No
I have read, or have had explained to me, information about the vaccines I am to be given, and the diseases the vaccines are intended to mitigate. I believe I understand the benefits and risks of the vaccine to be given. I authorize the vaccine to be given to me or to the person named above, for whom I am authorized to make this request.
*
Electronic Signature of Person Receiving Vaccine or Guardian of Person Receiving Vaccine
Today's Date
*
MM
DD
YYYY
FOR PHARMACY USE ONLY
Vaccine Given:
Date Administered:
Manufacturer:
Lot Number:
Expiration Date:
Injection Site:
Signature of Vaccine Administrator:
Thank you!
