信凯尔-美国专家智能预约平台

您希望在哪个城市接种新冠疫苗？/In which city do you want to get COVID vaccine

A.旧金山/San Fracisco B.洛杉矶/Los Angeles C.西雅图/Seattle D.休士顿/Houston E.芝加哥/Chicago F.纽约/New York G.华盛顿特区/Washington DC H.其他城市/Other cities

如果选择其他城市，请填写城市名/If choose other cities, please enter name of city

您希望接种新冠疫苗的日期和时间/Date and time you want to get the COVID-19 vaccine

如果选择其他日期和时间，请列出/If choose other dates and times, please specify:

您目前是否有以下症状？/Are you experiencing the following symptoms?

A.发烧/Fever B.否/Chill C.流鼻水/Running nose D.喉咙痛/Sore throat E.咳嗽/Cough F.身体酸痛/Bodyache or sore G.无/None of the above

您是否曾接种过新冠疫苗？/Have you ever received a dose of COVID-19 vaccine?

A.是/Yes B.否/No

若接种过，接种过几剂？/If yes, how many doses have you had?

A.一/one B.二/two C.三/three D.四/four

若接种过，接种的什么品牌？/If yes, which vaccine product received?

选择您最后一次接种的日期：/Enter the date when you received your last dose:

您需要接种哪种 COVID-19 疫苗？/Which COVID-19 vaccine is needed?
选择A：如果您接种第一剂加强针至少2个月以上或您接种初始两剂至少2个月以上；选择B：如果您尚未接种过初始两剂疫苗或如果您免疫功能低下并且需要额外剂量/

A.新型变异加强剂/Updated (Bivalent) Booster B.初始两剂疫苗接种/Primary COVID-19 series

您过去是否有过严重的过敏反应（如过敏性休克）？例如：因为过敏导致您接受了肾上腺素或EpiPen®治疗，或者您不得不去医院？/Have you ever had a severe allergic reaction (e.g., anaphylaxis) in the past? Example: a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?
包括在4小时内发生的过敏反应，导致荨麻疹，肿胀或呼吸困难，喘息/

A.是/Yes B.否/No C.不确定/Not sure

您是否因以下原因产生严重过敏反应？/Do you have a severe allergic reaction from any of the following?

A.因接种过新冠疫苗而严重过敏/Was the severe allergic reaction after receiving a COVID-19 vaccine? B.因接种其他疫苗/药品产生严重过敏反应/Was the severe allergic reaction after receiving another vaccine or injectable medication? C.因接受聚乙二醇或含有聚乙二醇的产品而严重过敏/Was the severe allergic reaction related to receiving Polyethylene Glycol or products containing Polyethylene Glycol? D.因接受聚山梨酯或含有聚山梨酯的产品而严重过敏/W as the severe allergic reaction related to receiving Polysorbate or products containing Polysorbate? E.我没有严重过敏/Never

（可多选）你是否患有以下慢性病？/Chronic diseases

您过去14天内是否接种过任何疫苗？/Have you received any vaccines in the past 14 days?

A.是/Yes B.否/No

如果有，请选择：/If so, please select:

您过去90天内是否使用单克隆抗体或血清等被动抗体治疗新冠？/Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?

A.是/Yes B.否/No

您的免疫系统是否因HIV感染或癌症等原因而减弱，或者您是否有服用免疫抑制药物或治疗方法？/Has your immune system been weakened by, for example, HIV infection or cancer, or are you taking immunosuppressive drugs or treatments?

A.是/Yes B.否/No C.不知道/Don't know

您是否有出血性疾病或正在服用血液稀释剂？/Do you have a bleeding disorder or are you taking a blood thinner?

A.是/Yes B.否/No C.不知道/Don't know

您是否正在怀孕或哺乳？/For women, are you currently pregnant or breastfeeding?

A.是/Yes B.否/No

病人资料/Patient Information

疫苗接种/Vaccination