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COVID-19 Vaccine Pre-Screening Questionnaire
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* Indicates required question
Name (First & Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Phone Number (please include area code).
*
Your answer
Do you have any health conditions? Select all that apply.
*
Cancer
Chronic Obstructive Pulmonary Disease (COPD)
Down Syndrome
Heart Conditions/cardiomyopathies
Organ transplant recipient
Type 2 Diabetes
Sickle Cell Disease
Pregnancy
Asthma
Cerebrovascular Disease
Cystic Fibrosis
Immunocompromised due to blood/bone transplant, immune deficiencies, HIV, corticosteroids or other immune-weakening medications
Neurological conditions (i.e., Dimentia)
Liver Disease
Pulmonary Fibrosis
Type 1 Diabetes
Obesity (moderate/severe)
I do not have any of the above health conditions.
Other:
Required
What is your current occupation?
*
Your answer
Are you a healthcare worker or first responder?
*
Yes
No
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