Is this your first COVID-19 vaccine shot?

Yes No

What is your current age?

What is your current temperature?

^oC

What is your current blood pressure?

Systolic Blood Pressure (Top Number)

Diastolic Blood Pressure (Bottom Number)

Have you been in contact with anyone who is testing/confirmed/undergoing treatment for
COVID-19 in the last 14 days?

Yes No

Are you experiencing any fever/runny nose/cough/trouble breathing?

Yes No

Have you previously tested positive for COVID-19?

Yes No

Are you currently pregnant or breastfeeding?

Pregnant
Breastfeeding
None

Do you have severe allergic reactions such as shortness of breath, swelling and hives all over your
body or other reactions due to vaccines?

Yes No

Do you have severe allergic reactions such as shortness of breath, swelling and hives all over your
body or other reactions after your first COVID-19 vaccine?

Yes No

Are you currently diagnosed with any heart/kidney/liver diseases?

Yes No

Are you currently diagnosed and receiving treatment for cancer?

Yes No

Are you currently receiving treatment for blood clotting, immune deficiency or received a
blood transfusion?

Yes No

Do you have a history of epilepsy?

Yes No

Are you currently diagnosed with Diabetes Mellitus (Type 2 Diabetes)?

Yes No

Are you currently diagnosed with HIV?

Yes No

Are you currently diagnosed with respiratory diseases?

(includes Asthma, Chronic Obstructive Pulmonary Disease)

Yes No

Have you received any other vaccine in the past month?

Yes No

Are you having any difficulties climbing up 10 steps?

Yes No

Do you often experience fatigue?

Yes No

Which of the following diseases are you diagnosed with?

Hypertension
Diabetes
Cancer
Chronic Respiratory Disease
Congestive Heart Failure
Chest Pain
Joint Pain
Stroke
Kidney Disease
Heart Attack
Asthma

Are you having any difficulties walking 100-200m (328-656 feet)?

Yes No

Have you experienced any significant weight loss in the past year?

Yes No

Are you eligible for a vaccine?

Is this your first COVID-19 vaccine shot?

What is your current age?

What is your current temperature?

What is your current blood pressure?

Systolic Blood Pressure (Top Number)

Diastolic Blood Pressure (Bottom Number)

Have you been in contact with anyone who is testing/confirmed/undergoing treatment for COVID-19 in the last 14 days?

Are you experiencing any fever/runny nose/cough/trouble breathing?

Have you previously tested positive for COVID-19?

Are you currently pregnant or breastfeeding?

Do you have severe allergic reactions such as shortness of breath, swelling and hives all over your body or other reactions due to vaccines?

Do you have severe allergic reactions such as shortness of breath, swelling and hives all over your body or other reactions after your first COVID-19 vaccine?

Are you currently diagnosed with any heart/kidney/liver diseases?

Are you currently diagnosed and receiving treatment for cancer?

Are you currently receiving treatment for blood clotting, immune deficiency or received a blood transfusion?

Do you have a history of epilepsy?

Are you currently diagnosed with Diabetes Mellitus (Type 2 Diabetes)?

Are you currently diagnosed with HIV?

Are you currently diagnosed with respiratory diseases?

(includes Asthma, Chronic Obstructive Pulmonary Disease)

Have you received any other vaccine in the past month?

Are you having any difficulties climbing up 10 steps?

Do you often experience fatigue?

Which of the following diseases are you diagnosed with?

Are you having any difficulties walking 100-200m (328-656 feet)?

Have you experienced any significant weight loss in the past year?

Have you been in contact with anyone who is testing/confirmed/undergoing treatment for
COVID-19 in the last 14 days?

Do you have severe allergic reactions such as shortness of breath, swelling and hives all over your
body or other reactions due to vaccines?

Do you have severe allergic reactions such as shortness of breath, swelling and hives all over your
body or other reactions after your first COVID-19 vaccine?

Are you currently receiving treatment for blood clotting, immune deficiency or received a
blood transfusion?