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Covid Assessment Form

Have you been sick in the past few days? Do you have symptoms of COVID-19 or have a fever today? *
Have you had a serious allergic reaction or a reaction within 4 hours to the COVID-19 vaccine before? *
Do you have allergies to polyethylene glycol [PEG]*, tromethamine (Moderna only) or polysorbate? *
Have you had a serious allergic reaction to a vaccine or medication given by injection (e.g., IV, IM), needing medical care? *
Have you received a vaccine in the past 14 days? *
Are you or could you be pregnant or breastfeeding? *
Do you have a weakened immune system or are you taking any medications that can weaken your immune system (e.g., high dose steroids, chemotherapy)? *
Do you have an autoimmune condition? *

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Covid Assessment Form