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Military Health System

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Patient Screening

See a collection of forms and questionnaires below that can be used to screen patients for contraindications and precautions to routine and non-routine immunizations. More will be added as they are published.

File Date
DHA Form 207, COVID-19 Vaccine Screening and Immunization Documentation, Version 26
October 2023
DHA Form 236, Pediatric (6 months-11 years) COVID-19 Vaccine Screening and Immunization Documentation, Version 13
October 2023
DHA Form 116, Pediatric and Adult Influenza Screening and Immunization Documentation
Pending update anticipated late August 2024 
DD Form 3110: Routine Immunization Screening Form: Pediatric
March 2020
DD Form 3111: Routine Immunization Screening Form: Adult
March 2020
Screening Checklist for Cholera Vaccine Feb. 23, 2021
Last Updated: July 11, 2024
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