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Screening Checklist for Contraindications to Vaccines for Children and Teens Mobile App

The Screening Checklist for Contraindications to Vaccines for Children and Teens mobile app will help parents and guardians determine which vaccines your child may be given today. If you answer “yes” to any question, it does not necessarily mean your child should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it. You can auto-populate a GoCanvas form with data provided by a reference file.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Screening Checklist for Contraindications to Vaccines for Children and Teens Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Screening Checklist for Contraindications to Vaccines for Children and Teens

  • Ico textbox

    Patient Name:

  • Ico date

    Date of Birth:

  • Ico statictext

    For parents/guardians: The following questions will help us determine which vaccines your child m...

  • Ico checkbox

    Is the child sick today?

  • Ico checkbox

    Does the child have allergies to medications, food, a vaccine component, or latex?

  • Ico checkbox

    Has the child had a serious reaction to a vaccine in the past?

  • Ico checkbox

    Has the child had a health problem with lung, heart, kidney or metabolic disease (e.

  • Ico checkbox

    If the child to be vaccinated is 2 through 4 years of age, has a healthcare provider told you th...

  • Ico checkbox

    If your child is a baby, have you ever been told he or she has had intussusception?

  • Ico checkbox

    Has the child, a sibling, or a parent had a seizure; has the child had brain or other nervous sy...

  • Ico checkbox

    Does the child have cancer, leukemia, HIV/AIDS, or any other immune system problem?

  • Ico checkbox

    In the past 3 months, has the child taken medications that weaken their immune system, such as c...

  • Ico checkbox

    In the past year, has the child received a transfusion of blood or blood products, or been given...

  • Ico checkbox

    Is the child/teen pregnant or is there a chance she could become pregnant during the next month?

  • Ico checkbox

    Has the child received vaccinations in the past 4 weeks?

  • Ico textbox

    Form completed by:

  • Ico date

    Date:

  • Ico textbox

    Form reviewed by:

  • Ico date

    Date:

  • ...and More!

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