blood cholesterol, diabetes, first-degree relative who had a Do you or a household member/close contact have diabetes? Self Yes No. Household Yes No …
| The purpose of this screening is to identify if you or a family member have |
|currently known health conditions that may possibly place you or your family members |
|at greater risk for serious side effects should you receive a smallpox vaccination |
|prior to the implementation of any community smallpox vaccination clinics |
| |
|Any information that you have provided in this health questionnaire and attached |
|volunteer application may be disclosed to and used by the Smallpox Vaccination |
|Clinic/SNS Planning Committee for planning purposes and volunteer assignment only |
|Any information you have provided on the health questionnaire will not be disclosed |
|to any individual outside the Smallpox Vaccination Clinic/SNS Planning Committee or |
|for any purpose other than stated above |
|Please circle or correct answer or answers |
|Have you ever received a smallpox vaccination? When if known: |Yes No Dont|
|
|Know |
|Have you ever had a serious reaction to any vaccine? |Yes No |
|If so, please describe type of vaccine and type of reaction: | |
| | |
|Have you ever had an allergic reaction to the antibiotics |Yes No |
|polymyxin B, streptomycin, tetracycline, or neomycin? | |
|Do you have 3 or more of the following risk factors: Smoke |Yes No |
|cigarettes, high blood pressure, high blood cholesterol, diabetes,| |
|first-degree relative who had a heart condition before the age of | |
|50? | |
|Have you had a previous heart attack also called myocardial |Yes No |
|infarction? | |
|Have you had angina pectoris chest pain caused by lack of blood |Yes No |
|flow to the heart? | |
|Have you ever been diagnosed with
cardiomyopathy? |Yes No |
|Have you ever been diagnosed with congestive heart failure? |Yes No |
|Have you ever had chest pain or shortness of breath with exertion |Yes No |
|activity? | |
|Do you have any other heart conditions for which you are under the|Yes No |
|care of a doctor? | |
|Do you or a household member/close contact have any form of cancer|Self |
|including leukemia? |Yes No |
| |Household Yes |
| |No |
|Are you or a household member/close contact taking anticancer |Self |
|drugs and/or x-ray or radiation treatments? |Yes No |
| |Household Yes |
| |No |
|Do
you or a household member/close contact have any form of immune|Self |
|system problem such as lupus, agammaglobulinemia, acquired immune |Yes No |
|deficiency syndrome AIDS or human immunodeficiency virus HIV? |Household Yes |
| |No |
|Have you or a household member/close contact had an organ or |Self |
|bone-marrow transplant? |Yes No |
| |Household Yes |
| |No |
|Are you or a household member/close contact taking cortisone, |Self |
|prednisone, or other steroids including eye drops containing |Yes No |
|steroids? Does not include inhalers |Household Yes |
| |No |
|Have you, or a household member/close contact ever been told by a |Self |
|doctor that you have eczema or atopic dermatitis?
|Yes No |
| |Household Yes |
| |No |
|Have you or a household member/close contact had an itchy, red, |Self |
|scaly rash that lasts more than 2 weeks and comes and goes? |Yes No |
| |Household Yes |
| |No |
|Do you or a household member/close contact have any other current |Self |
|skin conditions, such as burns, impetigo, varicella zoster |Yes No |
|chickenpox or shingles, psoriasis, herpes or severe or |Household Yes |
|uncontrolled acne? |No |
|Have you or a household member/close contact ever been diagnosed |Self |
|as having Dariers disease? May also be known as: Dariers |Yes No |
|syndrome, Darier-White disease, Lutz-Darier syndrome, Whites |Household Yes |
|disease, Whites syndrome
|No |
|Do you or a household member/close contact have diabetes? |Self |
| |Yes No |
| |Household Yes |
| |No |
|Are you being treated by a doctor for any other health conditions |Yes No |
|and want to know if you should be concerned about vaccination? | |
| |
|Other issues to be considered at time of receiving smallpox vaccination: |
|Have you received a transfusion of blood or plasma or any medicine|Not applicable at|
|containing antibodies immune or gamma globulin in the past 12 |this time |
|months? | |
|For women: Could you be pregnant or do you intend to become |Not applicable at|
|pregnant in the next 4 weeks? This information will be important |this time |
|at the time of
vaccination | |
|Do you have a household member/close contact who is pregnant? |Not applicable at|
| |this time |
|For women: Are you breastfeeding? |Not applicable at|
| |this time |
| | |
| | |
| | |
| |Initials__________|
| |____ |
Source:txkusa.org
