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:

  • ▢ 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
  • ▢ is pregnant
  • ▢ has a history of Guillain–Barré syndrome
  • ▢ was a preterm infant
  • ▢ has a severe or chronic illness
  • ▢ has a bleeding disorder
  • ▢ 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)

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:

  • ▢ 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.

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