Conversational form
Vaccination clinic registration form with the screening questions
A workplace flu clinic lives or dies on how fast the table moves, and every minute spent asking screening questions is a minute nobody else is being vaccinated. This form asks the nine screening questions before the day, explains what each answer changes, and ends with a four part consent that includes reporting to the register.
The form itself
The first screen of the form. A conversational form shows one question per screen, so the remaining screens are listed in the field table below. Nothing here can be filled in or submitted, so read it as a reference and build your own from the button above.
Every field, and what it collects
The complete field list, in the order respondents meet it.
- Who are we vaccinating?ProfileRequired
- The mobile matters here. If a screening answer needs discussing, a nurse rings before the clinic instead of having the conversation in front of your colleagues.
- Which site and clinic date?DropdownRequired
- Each clinic runs from 8am to 2pm. Pick the site you will actually be at that day rather than your usual one, because the nurse and the vaccine travel to a single location.
- Options: Port Melbourne warehouse, Tuesday 5 May · Port Melbourne warehouse, Wednesday 6 May · Truganina distribution centre, Thursday 7 May · Truganina distribution centre, Friday 8 May · Collins Street office, Tuesday 12 May · Collins Street office, Wednesday 13 May
- What is your date of birth?DateRequired
- Age decides which vaccine is used. People aged 65 and over are given the adjuvanted vaccine, which is a different product rather than a larger dose.
- Have you had a flu vaccine before?Single choiceRequired
- A first flu vaccine is not a reason to be turned away. It is a reason for the nurse to spend an extra minute with you.
- Options: Yes, last year · Yes, but not in the last two years · No, this would be my first · I am not sure
- Have you ever reacted badly to a vaccine?Single choiceRequired
- A sore arm, a mild fever or feeling tired for a day is expected and is not a reaction in this sense. The answers below describe the ones that change what happens at the table.
- Options: No · A local reaction, swelling or redness that lasted several days · A fever over 39 degrees within 48 hours · Anaphylaxis or a severe allergic reaction · Guillain Barre syndrome within six weeks of a flu vaccine · Something else, and I would like to discuss it
- Are you allergic to eggs?Single choiceRequired
- Egg allergy is asked because the vaccine is grown in eggs. Current Australian guidance is that people with egg allergy, including anaphylaxis, can be vaccinated in a standard clinic, so this answer changes the observation time rather than your eligibility.
- Options: No · Yes, a mild reaction such as a rash or an upset stomach · Yes, anaphylaxis · I am not sure
- Are you unwell today?Single choiceRequired
- A minor cold is fine. A fever of 38.5 degrees or higher means the vaccination is postponed, which is a delay of a week rather than a cancellation.
- Options: No, I feel well · A mild cold or sniffle, no fever · Yes, I have a fever · I am waiting on a test result
- Are you pregnant or breastfeeding?Single choiceRequired
- The flu vaccine is recommended at any stage of pregnancy and while breastfeeding, and it is funded under the National Immunisation Program for pregnant women. The nurse records the trimester.
- Options: No · Pregnant, first trimester · Pregnant, second trimester · Pregnant, third trimester · Breastfeeding · Prefer not to say
- Are you taking a blood thinner or do you have a bleeding disorder?Single choiceRequired
- This changes the needle technique and how long pressure is held on the site. It does not stop the vaccination.
- Options: No · Yes, warfarin · Yes, a direct oral anticoagulant such as apixaban or rivaroxaban · Yes, clopidogrel, aspirin or another antiplatelet · Yes, haemophilia or another bleeding disorder
- Anything else a nurse should know?Long textRequired
- Recent vaccines and immunosuppressant medicines both belong here. So does a shoulder you would rather nobody touched.
- ConsentMultiple choiceRequired
- Tick every statement. The nurse confirms your name and date of birth again at the table, which is a deliberate second check rather than a formality.
- Options: I have read what the vaccine is and what it does, and I consent to being vaccinated · My answers above are true and complete as far as I know · I will wait at the clinic for 15 minutes after the injection · I agree that my name, date of birth and vaccination date may be reported to the Australian Immunisation Register
Every screening question says what it changes
Screening questions get bad answers when people cannot tell whether a truthful answer will cost them the appointment. So each screen here carries a description under the question saying exactly what the answer affects. Egg allergy changes the observation time, not eligibility. A blood thinner changes the needle technique. A fever postpones by a week. A first flu vaccine buys an extra minute with the nurse. None of those are refusals, and saying so on the screen is the difference between an honest answer and a shrug.
The Australian pieces on this form
The consent list includes reporting the name, date of birth and vaccination date to the Australian Immunisation Register, because that reporting is mandatory for vaccines given in Australia and a consent screen that hides it is not consent. The date of birth question explains that people aged 65 and over receive the adjuvanted vaccine, which is a different product rather than a bigger dose. The pregnancy question notes that influenza vaccination is recommended at any stage of pregnancy and funded under the National Immunisation Program, which is the fact most people have not been told.
How to adapt this form
A childhood immunisation clinic replaces the pregnancy and anticoagulant screens with a birth weight question, a previous dose history and a parent or guardian consent, and moves the observation wait to 15 minutes with a named adult. A travel clinic keeps the reaction and allergy screens, adds a destination and departure date, and turns the single site dropdown into a two appointment booking because most travel schedules need a second visit. An aged care provider adds a resident room number and a substitute decision maker question, since consent is often given by somebody who is not in the room.
What makes this form work
Each screening question names its consequence
Egg allergy changes the observation time, a blood thinner changes the needle technique, a fever postpones by a week. People answer honestly when a truthful answer is visibly not a refusal.
The reaction question separates a sore arm from anaphylaxis
Five graded answers, from a local reaction lasting days through fever over 39 degrees to anaphylaxis and Guillain Barre. A single yes or no would collect mostly noise.
Consent includes the immunisation register in plain words
The fourth statement says the name, date of birth and vaccination date may be reported to the Australian Immunisation Register. That reporting happens either way, so it belongs on the screen rather than in a policy.
Questions people ask
Why run a screening questionnaire before the clinic rather than at the table?
Because a nurse asking nine questions in front of a queue is slow and public. Answering beforehand means the table visit is a confirmation rather than an interview, and anything that needs discussing is handled by a phone call before the day. The thank you screen promises exactly that, which is also the reason people answer the awkward questions honestly.
Should a conversational form be used for medical screening?
It suits it well. One question per screen means each screening question gets its own description, which a conversational form renders under the question and a classic form does not show at all. The person answering sees one decision at a time, which is how a nurse would ask, rather than a wall of medical questions in a single column.
Does ticking the consent box count as informed consent?
The tick records what was agreed, and the four statements are deliberately separate so each one is read. It is not the whole of consent. The nurse confirms name and date of birth at the table and answers questions there, which the last screen says plainly. Treat the form as the record and the conversation at the table as the consent.
Why ask about egg allergy if it does not stop the vaccination?
Because the influenza vaccine is grown in eggs and the answer changes how long somebody is observed afterwards. Current Australian guidance is that people with egg allergy, including anaphylaxis, can be vaccinated in a standard clinic. Asking and then explaining that is better than not asking, which leaves people assuming the worst and skipping the clinic.
Can the form stop someone with a fever from booking?
It does not try to. The fever answer is recorded and a nurse acts on it, because a temperature on the day of the form says nothing about the day of the clinic. The description explains that a fever means a postponement of about a week rather than a cancellation, which keeps people from hiding it in order to keep the slot.
Where do the answers go after the clinic?
Into the responses table for the provider account, and the CSV export puts one column per question with the profile block joined into a single column. With the email alert add on the submission also goes to the clinic nurse inbox as a formatted message, which is how a nurse reviews the day list without opening the builder.
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Written and checked by the OneCraft team. Last checked .