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Fort Norfolk Medical Associates
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FNM Medical Associates
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RiverFront Diagnostic Center
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Interested in receiving the COVID-19 vaccine?
Moderna Fact Sheet
Moderna PreScreening Doc
Name
*
Email
*
Cell Phone
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Age
*
Are you feeling sick today?
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Yes
No
Don't Know
Have you ever received a dose of COVID-19 vaccine?
*
Yes
No
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If yes, which vaccine product did you receive?
*
Pfizer
Moderna
Another Product
Which other Product?
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Have you ever had an allergic reaction to:
A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
*
Yes
No
Don't Know
Polysorbate
*
Yes
No
Don't Know
A previous dose of COVID-19 vaccine
*
Yes
No
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Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
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Yes
No
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(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
Have you received any vaccine in the last 14 days?
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Yes
No
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Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
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Yes
No
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Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
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Yes
No
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Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
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Yes
No
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Do you have a bleeding disorder or are you taking a blood thinner?
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Yes
No
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Are you pregnant or breastfeeding?
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Yes
No
Don't Know
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