Vaccination Registration - Great Mines Health Center

Health History

1. Are you feeling sick today?*

Yes
No
Unknown

2. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or Epi Pen or for which you had to go to the hospital?*

Yes
No
Unknown

3. Have you ever had a serious reaction after any vaccination or injectable medication including a previous dose of the COVID-19 vaccine?*

Yes
No
Unknown

4. In the past 14 days have you had contact with a confirmed COVID-19 patient?*

Yes
No
Unknown

5. Are you breastfeeding or pregnant?*

Yes
No
Unknown

6. Have you received passive antibody therapy as a treatment for COVID-19?*

Yes
No
Unknown

7. Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS or other immune system problems or taking medication that affects your immune system)*

Yes
No
Unknown

8. Do you have a bleeding disorder or are you taking a blood thinner?*

Yes
No
Unknown

9. Have you ever received a dose of COVID-19 vaccine?*

Yes
No
Unknown

Where did you receive your first vaccine?*

Great Mines
Other

How many vaccines Have you received?*

One
Two

What type of Vaccine?*

Pfizer
Moderna

Date of First Vaccine?*

Date of Second Vaccine?*

10. Have you received any vaccination within the last 14 days?*

Yes
No
Unknown

Where did you receive your first vaccine?

Great Mines
Other

Date of First Vaccine?*

What type of Vaccine?*

Pfizer
Moderna

Please list any health issues that may put you in a higher risk category.

Such as hypertension, diabetes, other autoimmune, BMI >40

I acknowledge*

The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the CICP to provide benefits to certain individuals or estates of individuals who sustain a covered serious physical injury as the direct result of !he administration or use of the covered countermeasures. The CICP can also provide benefits 10 certain survivors of individuals who die as a direct result of the administration or use of covered countermeasures identified in a PREP Act declaration. The PREP Act declaration for medical countermeasures against COVID-19 states that the covered countermeasures are any antiviral medication, any other drug, any biologic, any diagnostic, any other device, or any vaccine used to treat, diagnose, cure, prevent, or mitigate COVID-19, the transmission of SARS-CoV-2 or a virus mutating from SARS-CoV-2, or any device used in the administration of and all components and constituent materials of any such product. Information about the CICP and filing a claim is available by calling 1-855-266-2427 or visiting:
https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine
https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine

Yes

MUST CONTACT ORIGINAL VACCINATOR FOR SECOND VACCINATION. GMHC CAN NOT ADMINISTER YOUR SECOND VACCINE.

Step 1 of 3

Patient Demographic Information

Health History

Emergency Contact

Fact Sheet