Skill V Patient Screening for Pharmacist Consultation and Services

Screening Checklist for Contraindications to Injectable Influenza Vaccination

1. Is this vaccination for yourself or someone else? If for someone else, is the patient to be vaccinated younger than 6 months of age?

2. Is the patient over the age of 65 resulting in the need for CDC recommended higher dose?

3. Is the person to be vaccinated today showing any signs of illness?

4. Does the person to be vaccinated have allergies to any component of the vaccine?

5. Does the person have a severe allergy to chicken eggs?

Screening Checklist for Contraindications to Injectable Inactivated Poliovirus Vaccination

1. Does the person to be vaccinated have allergies to any component of the vaccine?

2. Is the person to be vaccinated today immune depressed in any way?

3. Does the person to be vaccinated live with anyone who has an immune deficiency disease?

4. Is there a suspected familial immune deficiency?

5. Is there possibility that the person being vaccinated is pregnant?

Screening Checklist for Contraindications to Injectable Rubella Vaccination

1. Does the person to be vaccinated have allergies to any component of the vaccine?

2. Is the person to be vaccinated today immunosuppressed?

3. Is the person being vaccinated receiving corticosteroids?

4. Has the person being vaccinated been diagnosed with tuberculosis?

5. Is there possibility that the person being vaccinated is pregnant or attempting to become pregnant?

Screening Checklist for Late Refill

1. How did the prescriber recommend you take this medication?

2. What methods do you use to help remember to take your medication?

3. What side effects have you experienced with the medication?

4. Has this medication helped relieve condition for which it was prescribed?

5. Are there any other reasons you do not take this medication as often as prescribed?

Screening Checklist for Possible Allergic Reaction

1. What medication were you taking when you noticed symptoms of concern?

2. Please describe your symptoms.

3. When did your symptoms begin?

4. Were any other medications taken during this time, including over-the-counter drugs?

5. Have you stopped taking the medication?