This checklist helps decide about vaccinating you or your child today. Please fill in the following information for your doctor/nurse.
Name of person to be vaccinated:
Date of birth:
Name of person completing this form:
Please indicate if the person to be vaccinated:
▢ is unwell today
▢ has a disease that lowers immunity (eg leukaemia, cancer, HIV) or is having treatment that lowers immunity (eg oral steroid medicines such as cortisone and prednisone, DMARDs [disease-modifying anti-rheumatic drugs], radiotherapy, chemotherapy)
▢ is an infant of a mother who was receiving highly immunosuppressive therapy (eg bDMARDs [biologic disease-modifying anti-rheumatic drugs]) during pregnancy
▢ has had a severe reaction following any vaccine
▢ has any severe allergies (to anything)
▢ has had any vaccine in the past month
▢ has had an injection of immunoglobulin, or received any blood products or a whole-blood transfusion within the past year
▢ identifies as an Aboriginal or Torres Strait Islander person
▢ does not have a functioning spleen
▢ is planning a pregnancy or anticipating parenthood
▢ is a parent, grandparent or carer of an infant ≤6 months of age
▢ lives with someone who has a disease that lowers immunity (eg leukaemia, cancer, HIV) or lives with someone who is having treatment that lowers immunity (eg oral steroid medicines such as cortisone and prednisone, DMARDs [disease-modifying anti-rheumatic drugs], radiotherapy, chemotherapy)
▢ is planning travel
▢ has an occupation or lifestyle factor(s) for which vaccination may be needed (discuss with doctor/nurse)
Note: Please discuss this information or any questions you have about vaccination with your doctor/nurse before the vaccines are given.
Before any vaccination takes place, your doctor/nurse should ask you:
▢ Did you understand the information provided to you about vaccination?
▢ Do you need more information to decide whether to proceed?
▢ Did you bring your/your child’s vaccination record card with you?
It is important for you to receive a personal record of your vaccinations or your child’s vaccinations. If you do not have a record, ask your doctor/nurse to give you one. Bring this record with you every time you or your child visit for vaccination. Make sure your doctor/nurse records all vaccinations on it.
Printed content may be out of date. For up to date information, always refer to the digital version: https://immunisationhandbook.health.gov.au/resources/handbook-tables/table-pre-vaccination-screening-checklist.