Schedule your vaccinations

1. Do you feel sick today?

2. Do you have any health conditions such as heart disease, diabetes or asthma? If yes, please check it:

3. Do you have allergies to latex, medications, food or vaccines (e.g., eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)? If yes, please list:

4. Have you ever had a reaction (allergic or otherwise) after receiving an immunization, including fainting or feeling dizzy?

5. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré Syndrome (a condition that causes paralysis) or other nervous system problem?

6. Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS or transplant)?

7. For women: Are you pregnant or considering becoming pregnant in the next month?

8. Have you received any vaccinations or skin tests in the past four weeks? If yes, please list:

9. Are you currently on home infusions, weekly injections such as Humira™ (adalimumab), Remicade™ (infliximab) or Enbrel™ (etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?

10. Are you currently taking high-dose steroid therapy (prednisone > 20 mg/day or equivalent) for longer than two weeks?

11. Have you received a transfusion of blood, blood products or been given a medication called immune (gamma) globulin in the past year?

12. Are you currently taking any antibiotics, antiviral or antimalarial medications? (Typhoid only)

13. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)

14. Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only)

15. Do you have a nasal condition serious enough to make breathing difficult (e.g., very stuffy nose)?