If you answer yes to any of these questions, well then you might not be able to get the China Virus vaccine. A nurse emailed this to me and said this form was given to all the healthcare staff at her hospital, and if you answered no to any of the questions, your out of luck for the vaccine.
COVID Screening Questions (yes, no)
1. In the past two weeks have you tested positive for COVID-19?
2. In the past 90 days have you received passive antibody therapy as part of COVID-19 treatment?
3. In the past two weeks, have you had contact with anyone who tested positive for COVID-19 — were
you at a distance of six feet or less for a period of 15 or more minutes without wearing appropriate
personal protective equipment?
4. Have you had the new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue,
muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?
5. Are you below the age of 16?
Immunization Screening Questions (yes, no)
1. Are you sick today? (For example, a cold or a fever or a new illness)
2. Do you have allergies or reactions to any foods, medicines, vaccines, or latex?(For example, eggs,
gelatin, neomycin, thimerosal)
3. Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting?
particularly with vaccines? Has any physician or other health care provider ever cautioned you about
receiving certain vaccines or receiving vaccines outside of a medical setting?
4. Have you had a seizure or a brain or other nervous system problem or Guillain Barre?
5. Do you have a blood disorder or take a blood thinner or anticoagulation medication? (For example,
6. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma,
kidney disease, metabolic disease (like diabetes), anemia, or other blood disorder?
7. Do you have cancer, leukemia, HIV/AIDS, rheumatoid arthritis, ankylosing spondylitis, Chron ‘s disease,
or any other immune system problem?
8. Do you have a weakened immune system or in the past three months, taken medications that weaken
it, such as cortisone, prednisone, or other steroids, anticancer drugs, or radiation treatments?
9. During the past year, have you received a transfusion of blood or blood products, or been given
immune (gamma) globulin, or an antiviral drug?
10. For women, are you pregnant or is there a chance you could become pregnant during the next month?
11. Have you received any vaccinations or TB skin test in the past four weeks?
If you answer yes to any of these questions, you should not receive the vaccine at this time, you
should contact your primary care provider for next steps.