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Pre-Vaccination Screening & Readiness Checklist

A pre-appointment screening tool for clinics, pharmacies, and occupational health programs to flag symptoms, allergies, and contraindications before a vaccine is administered. An AI follow-up interview digs into any hesitancy or concerns a patient flags, so staff can address real barriers before the appointment instead of guessing at them.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

12 questions · ~7 min
Q01
Message

Thanks for taking a moment before your vaccination appointment. This quick checklist (about 7 minutes) helps our team make sure the vaccine is right for you today and address any concerns beforehand.

Q02
Multiple ChoiceRequired

Are you experiencing any of the following today?

  • Fever or chills
  • Cough or sore throat
  • Feeling generally unwell
  • Currently taking antibiotics for an infection
Q03
Multiple ChoiceRequired

Have you ever had an allergic reaction to a vaccine, medication, or food (such as latex or eggs)?

  • Yes
  • No
  • Not sure
Q04
Short Text

If you answered yes to the previous question, briefly describe the reaction and what caused it.

Q05
Multiple ChoiceRequired

Do any of the following currently apply to you?

  • I am pregnant or breastfeeding
  • I have a weakened immune system or take immunosuppressive medication
  • I have a bleeding disorder or take blood thinners
  • I have received another vaccine in the past 14 days
Q06
Opinion ScaleRequired

How confident do you feel about receiving this vaccine today?

Scale: 1 – 10
Min:Not confident at allMax:Completely confident
Q07
Multiple Choice

What, if anything, concerns you about getting vaccinated today?

  • Fear of needles
  • Possible side effects
  • Not sure the vaccine is necessary for me
  • Timing or scheduling
  • Cost or insurance coverage
Q08
AI Interview

Probe the specific concern the respondent selected (or, if they selected none, briefly confirm nothing is being left unsaid) and connect it to their confidence rating. For anyone below the midpoint on confidence, ask what information or reassurance would need to happen for them to feel ready, and whether a past experience is driving the hesitation. If they flagged an allergy or a condition like pregnancy or immunosuppression, gently confirm whether they've discussed this with the provider administering the vaccine today.

Q09
Rating Scale

How clear was the information your provider gave you about this vaccine before today's appointment?

Range: 1 – 5
Min:Not clear at allMax:Extremely clear
Q10
Dropdown

What is your age range? (Optional)

  • Under 18
  • 18-29
  • 30-44
  • 45-59
  • 60-74
  • 75 or older
  • Prefer not to say
Q11
Multiple Choice

What is your gender? (Optional)

  • Female
  • Male
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q12
Message

Thank you for completing this checklist. Your answers help our clinical team confirm the vaccine is safe for you today and address any concerns before you're called in.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Includes a dedicated multiple-choice question on vaccination concerns followed by an AI follow-up interview that probes the specific concern the respondent selected, so staff get real reasons instead of a checked box
  • Combines clinical screening items (symptoms, allergy history with a follow-up description field, contraindication flags) with a readiness/confidence opinion scale, so both medical risk and hesitancy are captured in one flow
  • Asks respondents to rate how clearly their provider explained the vaccine beforehand, giving clinics a feedback signal on their own counseling process, not just a pass/fail screen
  • Keeps demographic questions (age range, gender) optional and clearly labeled, and closes with a plain-language thank-you message reassuring respondents their answers inform clinical follow-up

Jotform

Pre-Vaccination Checklist for COVID-19 Vaccines Form Template

This is a fielding-ready static form built for COVID-19 pre-vaccination screening, using Jotform's drag-and-drop form builder and integrations. It covers standard symptom and eligibility checklist items but is scoped specifically to COVID-19 rather than vaccines in general. Like most Jotform templates, it can be customized with conditional logic but relies on fixed question branches rather than open-ended AI probing.

What it does well

  • Purpose-built for COVID-19 vaccination screening workflows
  • Easy to customize within Jotform's widely-used form builder
  • Likely supports conditional logic to show/hide fields based on answers

Where it falls short

  • Static checklist format with no adaptive AI follow-up to explore hesitancy or ambiguous answers
  • Scoped to COVID-19 specifically, not a general-purpose vaccine readiness tool
  • No automated per-response quality scoring or auto-generated clinical-readiness report

SurveySparrow

Pre-Vaccination Checklist Template

SurveySparrow offers a conversational-style survey template for pre-vaccination screening, which fits the same use case of flagging symptoms and history before an appointment. Its chat-like interface makes the form feel more conversational than a plain form, but the underlying questions are still fixed and scripted rather than adaptively generated. There is no indication it interviews respondents further on any concerns they raise.

What it does well

  • Conversational survey format that may feel friendlier than a static form
  • Templated for the specific pre-vaccination healthcare use case
  • Part of a broader healthcare template library, suggesting reasonable customization options

Where it falls short

  • No adaptive AI interview to dig into specific concerns a respondent flags
  • No published methodology on how quality or completeness of responses is assessed
  • No mention of voice-based interview options or guided screen-share tasks for clinical staff review

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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