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Acute ill w/fever
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Aller react 1st COVID-19 dose
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Hx chronic diseases/immunodeficiency
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Hx of Major illnesses and injuries
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Immunodef
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Hx coag disorder &/or bld-thin med
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Allergies
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Hx of Allergies
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AE p vaccine
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Vaccination AE
?
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Pregnant/Nursing
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Vacc last 14 D
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Rcvd COVID-19 vaccine
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Date+time of vaccination
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Manufacturer name Vaccine
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