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Vaccine Risk Assessment
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Vaccine Risk Assessment
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Vaccine risk assessment
Current Age (Select one):
9 to 18 years
19 to 49 years
49 to 59 years
60 years and above
Do you have any of the following medical conditions?
Diabetes
Hypertension
Heart disease
Asthma / COPD / Lung disease
Kidney disease
Liver disease
Cancer
Autoimmune disorder
Neurological condition
Obesity
Are you currently
On steroids or immunosuppressive medication?
Undergoing chemotherapy?
HIV positive?
Post organ transplant?
Frequently hospitalized?
Do you
Smoke?
Consume alcohol frequently?
Travel frequently?
Work in crowded environments?
Use public transport daily?
Live with elderly individuals?
Live with young children?
Occupation category
Healthcare worker
Corporate employee
Teacher/school staff
Work in crowded environments?
Hospitality/travel worker
Factory/industrial worker
Student
None of the above
Have you travelled or plan to travel internationally in next 12 months?
America / Europe
South / South-East Asia
Africa and Latin America
Middle East
None of the above
Applicable for females only
Pregnancy / Family Planning
Are you pregnant?
Planning pregnancy?
Recently delivered?
None of the above
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