Adult Vaccination Assessment Tool - Adult Immunization

Q1.

Can you tell us your gender ?

Male

Female

Other

Q2.

Can you tell us your year of Birth ?

Q3.

HAVE YOU EVER TAKEN THE DPT (Diphtheria, Tetanus, Pertussis) VACCINE?

Yes, Atleast once in last 10 years

Yes, in my Childhood

Yes, within last year

Don't Remember

Never

HAVE YOU EVER TAKEN THE Influenza Vaccine?

Yes, Atleast once in last 10 years

Yes, in my Childhood

Yes, within last year

Don't Remember

Never

HAVE YOU EVER TAKEN THE PCV (Pneumococcal Conjugate) VACCINE?

Yes, Atleast once in last 10 years

Yes, in my Childhood

Yes, within last year

Don't Remember

Never

HAVE YOU EVER TAKEN THE TD/DT (Tetanus, Diphtheria Vaccine) VACCINE?

Yes, Atleast once in last 10 years

Yes, in my Childhood

Yes, within last year

Don't Remember

Never

HAVE YOU EVER TAKEN THE Pneumococcal polysaccharide vaccine (PPSV23) VACCINE?

Yes, Atleast once in last 10 years

Yes, in my Childhood

Yes, within last year

Don't Remember

Never

Q4.

Will you be travelling abroad in the near future?

Yes

No

Not Sure

Q5.

Do you smoke?

Yes

No

Occassionally

Q6.

Do you drink alcohol?

Yes

No

Occassionally

Q7.

Have you tested positive for COVID-19 in the past?

Yes

No

Q8.

Do you suffer from any of the following disease?

Heart Disease

Diabetes

Chronic Lung Disease (For Example – Asthma & Chronic Obstructive Pulmonary Disease) [COPD]

Kidney Failure, End - Stage Renal Disease or on Dialysis

Chronic Liver Disease (For Example – Cirrhosis or Alcoholic Liver Disease) or Hepatitis C Infection

Spleen has been damaged or removed (For Example – Due to Surgery or Sickle Cell Disease), Cancer or Cancer Treatment

Bone Marrow Transplant (Or any other transplant)

Not Applicable

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About Adult Vaccination

Get A Free Adult Vaccination Assessment

Q1.

Can you tell us your gender ?

Q2.

Can you tell us your year of Birth ?

Q3.

HAVE YOU EVER TAKEN THE DPT (Diphtheria, Tetanus, Pertussis) VACCINE?

HAVE YOU EVER TAKEN THE Influenza Vaccine?

HAVE YOU EVER TAKEN THE PCV (Pneumococcal Conjugate) VACCINE?

HAVE YOU EVER TAKEN THE TD/DT (Tetanus, Diphtheria Vaccine) VACCINE?

HAVE YOU EVER TAKEN THE Pneumococcal polysaccharide vaccine (PPSV23) VACCINE?

Q4.

Will you be travelling abroad in the near future?

Q5.

Do you smoke?

Q6.

Do you drink alcohol?

Q7.

Have you tested positive for COVID-19 in the past?

Q8.

Do you suffer from any of the following disease?

Thank You for answering the assessment questions. To view your results, please fill in the details below.