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