You may well be given this kind of questionnaire form to complete just before you are given the Covid Vaccine at a vaccination Centre.
Below is an English sample.

COVD-19 VACCINATION QUESTIONNAIRE
Name: ………………………………………………………………………
First name: ………………………………………………………………..…
Date of birth: ………………………………………………………
Social security number: ……………………………………………
Have you had a positive test (PCR or antigenic) during the last three months?                                 Yes No
Do you have a fever today?                                                                                                                            Yes No
Have you received a vaccine in the last two weeks?                                                                                Yes No
If yes, which one: ………………………………….…
Do you have a history of allergy or hypersensitivity to certain substances or with other vaccines?      Yes No
Do you have a bleeding disorder?
(in particular a decrease in the number of platelets or anticoagulant treatment) ?                           Yes No
Are you pregnant?                                                                                                                                             Yes No
Are you breastfeeding?                                                                                                                                    Yes No

For the doctor

Date / Signature