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Patient name: Date of birth: (mo.) (yr.) (day) Screening Questionnaire for Child and Teen Immunization For parents/guardians: The following questions will help us determine which vaccines your child.

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Can vaccines cause side effects? Which vaccines does my child need and when? Could multiple vaccines given at the same time overwhelm my child's immune system? What ingredients are in vaccines and what do they do?

If a question is not clear, please ask your healthcare provider to explain it. No. ... Is the person to be vaccinated sick today? Does the person to be vaccinated have an allergy to eggs or to a component of the vaccine? Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?

The U.S. Centers for Disease Control and Prevention (CDC) recommends routine vaccination to prevent vaccine-preventable diseases that occur in infants, children, adolescents, and adults. Screenings are medical tests that doctors use to check for certain disorders before there are any symptoms.

Patient and parent barriers to immunization include: parents may lack knowledge about childhood vaccinations, have unreasonable fears about vaccine safety, or lack transportation. They may not be aware of the threat of vaccine-preventable illness or that safe and effective vaccines are available against these diseases.

Has the person to be vaccinated ever received a dose of COVID-19 vaccine? If yes, which vaccine product was administered? How many doses of COVID-19 vaccine were administered? Did you bring the vaccination record card or other documentation?

Would a monetary incentive offered by [Company name] change your mind? Would another type of incentive offered by [Company name], such as paid time off, change your mind? Do you have a medical reason for not receiving the COVID-19 vaccine? Do you have a religious objection to receiving the COVID-19 vaccine?

What's a VIS? A VIS or Vaccine Information Statement is a document, produced by CDC, that informs vaccine recipients – or their parents or legal representatives – about the benefits and risks of a vaccine they are receiving.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232