GAD 7 score Watch a video about consent for this vaccine What is your name? * What is your date of birth? * Are you filling this form in for yourself for somebody else Person receiving the vaccines details: What is their name? What is their date of birth? * Please explain your relationship to them and the legal basis for providing consent Are you/the person you're completing this for: Male Female You are due to have your COVID vaccine soon. It is important to understand what vaccination involves, including the risks and benefits. Please take some time to read through the following information and then record your consent. You can return to this form at any time and complete it. Information: You can see the full patient information leaflet about the vaccine here for Pfizer vaccine and here for AstraZeneca vaccine . What is the vaccine and what is it used for? The vaccine used for active immunisation to prevent COVID19. It is given to adults and adolescents from 16 years. The vaccine triggers the body’s natural production of antibodies and stimulates immune cells to protect against COVID-19. How is the vaccine given? It is given as an injection into the muscle of your upper arm. You will receive 2 injections, separated by time governed by the government. Protection against COVID-19 disease may not be effective until at least 7 days after the second dose How safe is the vaccine? Any coronavirus vaccine that is approved must go through all the clinical trials and safety checks all other licensed medicines go through. The UK has some of the highest safety standards in the world. Vaccines will only be used if they are approved by the MHRA. The MHRA has been monitoring every stage of coronavirus vaccine development. So far, thousands of people have been given a coronavirus vaccine and no serious side effects or complications have been reported. Who shouldn't have the vaccine? You should talk to your doctor if: You have known allergies to any of the constituents of the vaccine (see list below) A history of anaphylaxis or severe allergy previously had any problems following previous administration of COVID Vaccine such as allergic reaction or breathing problems a severe illness with high fever. However, a mild fever or upper airway infection, like a cold, are not reasons to delay vaccination. a weakened immune system, such as due to HIV infection, or are on a medicine that affects your immune system a bleeding problem, bruise easily or use a medicine to inhibit blood clotting Constituents of the vaccine ALC-0315 = (4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate) ALC-0159 = 2[(polyethylene glycol)-2000]-N,N-ditetradecylacetamide 1,2-Distearoyl-sn-glycero-3-phosphocholine cholesterol potassium chloride potassium dihydrogen phosphate sodium chloride disodium hydrogen phosphate dihydrate sucrose I have concerns about the above information Yes No Please explain your concerns * Side Effects Like all vaccines, COVID-19 mRNA Vaccine BNT162b2 can cause side effects, although not everybody gets them. Most side effects are mild or moderate and go away within a few days of appearing. If side effects such as pain and/or fever are troublesome, they can be treated by medicines for pain and fever such as paracetamol. Side effects may occur with following frequencies: Very common: may affect more than 1 in 10 people pain at injection site tiredness headache muscle pain chills joint pain fever Common: may affect up to 1 in 10 people injection site swelling redness at injection site nausea Uncommon: may affect up to 1 in 100 people enlarged lymph nodes feeling unwell Important information for women There is currently limited data available on the use of this vaccine in pregnant women. If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before you receive this vaccine. As a precaution, you should avoid becoming pregnant until at least 2 months after the vaccine. I confirm I have understood the above and am not pregnant, and that I will delay any planned pregnancy until 2 months after I have received the vaccine. Yes Driving and operating machinery COVID-19 mRNA Vaccine BNT162b2 has no or negligible influence on the ability to drive and use machines. However, some of the effects mentioned previously may temporarily affect the ability to drive or use machines. Do not drive or operate machinery until you are sure that you are not affected. Have you had COVID infection in the last 4 weeks? Yes No I confirm I have not had anaphylaxis or severe allergy previously I have not had anaphylaxis or severe allergy previously I HAVE had anaphylaxis or severe allergy previously Having read and understood the previous information, do you consent to receiving the vaccination? * Yes No Having read and understood the previous information, do you consent to the person named previously receiving the vaccination? Yes No Please explain your concerns about the vaccination: * Please give more details about your history of anaphylaxis or severe allergy Anxiety questionnaire How often have you been bothered by the following over the past 2 weeks? Feeling nervous, anxious or on edge: * Not at all Several days More than half the days Nearly every day Not being able to stop or control worrying: * Not at all Several days More than half the days Nearly every day Worrying too much about different things: * Not at all Several days More than half the days Nearly every day Trouble relaxing: * Not at all Several days More than half the days Nearly every day Being so restless that it's hard to sit still: * Not at all Several days More than half the days Nearly every day Becoming easily annoyed or irritable: * Not at all Several days More than half the days Nearly every day Feeling afraid as if something awful might happen: * Not at all Several days More than half the days Nearly every day Your GAD7 score is: Thank you The information you've entered today will be sent to your doctor for review. Submit Page last reviewed: 05 May 2021