Professional Documents
Culture Documents
Health Assessment Form
Health Assessment Form
Has no severe allergic reaction after the 1st dose of the vaccine? ❏ ❏
➢ If with allergy or asthma , will the vaccinator able to monitor the patient for 30
❑ ❑
minutes?
❑ Fever/chills ❑ Fatigue
❑ Headache ❑ Weakness
❑ Cough ❑ Loss of smell/taste ❏ ❏
❑ Colds ❑ Diarrhea
❑ Sore throat ❑ Shortness of breath/difficulty in
❑ Myalgia breathing
❑ Fatigue
Has not been previously treated for COVID-19 in the past 90 days? ❏ ❏
Has not received convalescent plasma or monoclonal antibodies for COVID-19 in the
❏ ❏
past 90 days?
Not Pregnant? ❏ ❏
Birthdate: Sex:
SPECIAL PRECAUTION
YES OBSERVE FOR 30
NO With allergy to food, egg, medicine?
MINS
DEFER
Manifesting any of the following symptoms:
YES REFER TO MD.
NO RESCHEDULE
● Fever/chills, headache, cough, colds, sore throat, myalgia,
fatigue, weakness, loss of smell/taste, diarrhea, shortness of AFTER FULL
breath/difficulty in breathing RECOVERY.
VACCINATE
RESCHEDULE
NO YES
Have history of exposure to confirmed or suspected COVID-19 AFTER
case in the past 2 weeks? QUARANTINE
COMPLETION
NO YES
Have been previously treated for COVID-19 in the past 90 RESCHEDULE
days? AFTER 90 DAYS
NO YES RESCHEDULE
Have received convalescent plasma or monoclonal antibodies
for COVID-19 in the past 90 days? AFTER 90 DAYS
YES RESCHEDULE IF IN
NO Pregnant?
FIRST TRIMESTER
NO YES
Have received any vaccine in the past 2 weeks? RESCHEDULE