Child and Teen Immunization Screening Questionnaire

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Product number R4060
Date published April 2009
Description
Save valuable time and make sure that infants, children, and teens are fully screened for vaccine precautions and contraindications by using these simple one-page questionnaires of 11 questions. Patients or their caregivers respond to questions by checking "yes" and "no" boxes while waiting to be seen. Staff reviews patient answers during the visit. Included for no extra charge is the Spanish version of the questionnaire printed on the back side of the patient form.
Child and teen immunization screening questionnaires for vaccine precautions and contraindications are available in convenient tear-off pads of 100 sheets of ivory paper. Each English/Spanish pad comes shrink-wrapped with 4 ivory cardstock healthcare professional reference cards (available in English only) that list explanations for each of the 11 questions on the screening questionnaire.
Specifications
8 1/2" x 11" pads of 100 two-sided opaque ivory paper patient forms. Side one is in English and side two is in Spanish. Designed to allow room for 2 or 3 hole punches on the top and sides of the patient form. Each pad of forms is shrink-wrapped with 4 sturdy healthcare professional reference cards printed in English on ivory 110# cardstock.
Pricing
1 pad
$16.00 each
2   pads
$12.00 each
3   pads
$11.00 each
4-9   pads $10.00 each
10-24   pads $ 9.50 each
25-49   pads $ 9.00 each
50+   pads Please call.
For quotes on larger quantities or customizing call 651-647-9009 or email admininfo@immunize.org
Credits
Created and distributed by the Immunization Action Coalition.

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