Illini Pediatrics LLC, DBA Ideal Pediatrics

If patient is a minor

Yes

No

Yes

No

If yes, you MUST bring documentation of your previous dose.

Pfizer

Moderna

Johnson&Johnson

Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.

Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.

A previous dose of COVID-19 Vaccine

This would include a severe allergic reaction (e.g. anaphylaxis) that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include and allergic reaction that caused hives, swelling, or respiratory distress including wheezing.

Yes

No

This would include a severe allergic reaction (e.g. anaphylaxis) that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include and allergic reaction that caused hives, swelling, or respiratory distress including wheezing.

Am a female between ages 18 and 49 years old

Had a severe allergic reaction to something other than a vaccine or injectable therapy such as food, pet, venom, environmental or oral medication allergies.

Had COVID-19 and was treated with monoclonal antibodies or convalescent serum.

Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection.

Have a weakened immune system (i.e., HIV infection, cancer)

Take immunosuppressive drugs or therapies

Have a bleeding disorder

Take a blood thinner

Have a history of herparin-induced thrombocytopenia (HIT)

Am currently pregnant or breastfeeding

Have received dermal fillers.

Illini Pediatrics LLC, DBA Ideal Pediatrics

Available Forms

Prevaccination Checklist for COVID-19 Vaccines

Prevaccination Checklist for COVID-19 Vaccines