Pre-vaccination screening checklist

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:   

Age today:       

Name of person completing this form:

Please indicate if the person to be vaccinated:

Please specify: 

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:

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.

Last updated: 
8 June 2018
Last reviewed: 
8 June 2018