|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:
Name of person completing this form:
Please indicate if the person to be vaccinated:
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.