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Screening Questionnaire for Adult Hepatitis Vaccine Program For patients: The following questions will help us determine which vaccines you may be given today. If you answer “yes” or “no” to any question, it does not necessarily mean you will not be vaccinated. Confidentiality is strictly protected. Your answers are only used to determine which vaccines you are eligible to receive at this visit. If a question is not clear, please ask the nurse to explain it. Please circle your answer: Are you a man who has sex with men? Yes No Have you been diagnosed with Hepatitis C? Yes No Unknown Have you been diagnosed with Hepatitis B? Yes No Unknown Are you a sexual or household contact of a person diagnosed with Hepatitis B? Yes No Unknown Have you been diagnosed with HIV/AIDS? Yes No Unknown Are you a sexual contact of a person with a sexually transmitted disease or HIV? Yes No Unknown Are you or have you been a patient in a sexual health clinic? Yes No Are you currently using illicit drugs? Yes No Have multiple sex partners Yes No Are homeless/living on the street Yes No Currently in a drug or alcohol abuse program Yes No Inmate in correctional facility Yes No Living a group home Yes No Asian screening client Yes No Do you fall into any of the below listed categories? General Vaccination Questionnaire for Adults: Are you sick today? Do you have allergies to medications, food, or any vaccine? Have you ever had a serious reaction after receiving a vaccination? Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? Do you have cancer, leukemia, AIDS, or any other immune system problem? Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had x-ray treatments? Have you had a seizure, brain, or other nervous system problem? During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin? For women: Are you pregnant or is there a chance you could become pregnant during the next month? Have you received any vaccinations in the past 4 weeks? Yes Yes Yes No No No Unknown Unknown Unknown Yes Yes No No Unknown Unknown Yes Yes No No Unknown Unknown Yes No Unknown Yes Yes No No Unknown Unknown
