Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

1. Have you ever had a serious allergic reaction (anaphylaxis) that needed medical treatment: *

I) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine, OR II) to any of the vaccine ingredients, including polyethylene glycol known as PEG? If yes, you cannot get this vaccine. You should get a different type of vaccine in a specialist centre. Talk to your GP. You may need specialist advice. If no, GO TO NEXT QUESTION.

Yes

No

1a. Have you ever had a serious allergic reaction (anaphylaxis) to Trometamol (a contrast dye used in MRI radiological studies)? *

If yes, you cannot get the Moderna COVID-19 vaccine. But you can have a different vaccine. Talk to your GP. If no, GO TO NEXT QUESTION

Yes

No

2. Have you ever had a serious allergic reaction (anaphylaxis): *

I) after taking multiple different medications, with no reason known for the reaction. This may mean you are allergic to polyethylene glycol (PEG) OR II) after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR III) for unexplained reasons. This may mean you are allergic to polyethylene glycol (PEG)? If yes, you cannot get this vaccine. Talk to your GP or doctor to check if you are suitable for another type of COVID-19 vaccine. You may need specialist advice. If no, GO TO NEXT QUESTION.

Yes

No

3. Have you ever had: Mastocytosis/idiopathic anaphylaxis *

I) Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body's tissues) OR II) idiopathic anaphylaxis. This is a serious allergic reaction (anaphylaxis) with no known cause. OR III) a serious allergic reaction (anaphylaxis) due to food, medication or venom from an insect or animal? If yes, you can still get the vaccine, BUT, you should be observed for 30 minutes after you are vaccinated. GO TO NEXT QUESTION If no, GO TO NEXT QUESTION.

Yes

No

4. Have you had myocarditis (inflammation of the heart muscle) after having a previous dose of the Moderna or Pfizer/BioNTech COVID-19 vaccine? *

If yes, you cannot get this vaccine. Talk to your GP or doctor to check if you are suitable for another type of COVID-19 vaccine. If no, GO TO NEXT QUESTION.

Yes

No

5. Have you had pericarditis (inflammation of the lining around the heart) after having a previous dose of the Moderna or Pfizer/BioNTech COVID-19 vaccine? *

If yes, GO TO QUESTION 5b. If no, GO TO NEXT QUESTION.

Yes

No

5b. Since you had pericarditis (inflammation of the lining around the heart) after a previous dose of the Moderna or Pfizer/BioNTech COVID-19 vaccine, a specialist doctor must approve you to get this vaccine. Has your COVID-19 vaccination been approved by a specialist doctor?

If yes, GO TO NEXT QUESTION. If no, you cannot get this vaccine. Talk to your GP or doctor to check if you are suitable for another type of COVID-19 vaccine. You may need specialist advice.

Yes

No

6. Have you tested positive for COVID-19 within the last 3 months? *

If yes, you should delay getting a vaccine until you have recovered from COVID-19 and it has been at least 3 months since you tested positive or developed symptoms, or 3 months from your first positive PCR test if you did not have symptoms.

Yes

No

7. Do you have a bleeding disorder or are you on anti-coagulation therapy? *

If yes, you can still get a vaccine if you have a bleeding disorder or take anti-coagulation medicines. But tell your vaccinator about your condition.

Yes

No

8. Are you pregnant? *

If you are pregnant the Covid 19 vaccine is recommended for you. You can get the vaccine at any stage of pregnancy.

Yes (complete questions 8a, 8b, & 8c)

No (skip to question 9)

8a. Have you had a booster dose already in this pregnancy?

If yes, you don’t need a booster dose unless you have been diagnosed with a weak immune system. If you have been diagnosed with a weak immune system, speak to your vaccinator.

Yes

No

8b. Have you had COVID-19 infection or a COVID-19 vaccine in the last 6 months?

If yes you should wait at least 6 months from your last COVID-19 infection or COVID-19 vaccine dose to get a booster dose.

Yes

No

8c. Have you had a COVID-19 vaccine in the last 12 months?

If yes your vaccinator will talk to you about the best timing for your booster dose. If no you are eligible for vaccination today but ideally the vaccine should be given between 20 and 34 weeks of pregnancy.

Yes

No

9. Are you 29 years of age or younger? *

If yes, you will be offered a dose of Pfizer/BioNTech (Comirnaty®). If no, you will be offered either a dose of Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®)

Yes

No

10. Have they had the Mpox or smallpox vaccine (Imvanex or Jynneos) in the last 4 weeks?

If yes, you cannot get this vaccine today. You need to wait 4 weeks after getting these vaccines before getting a COVID-19 vaccine.

Yes

No