Covid jab France: Translation of the medical question form

There is a basic medical questionnaire to fill out before getting the vaccination in France. We translate it here into English.

3 March 2021
The medical form consists of seven questions relating to your health and previous experience with vaccinations
By Connexion journalist

When you go to get a Covid-19 vaccination you will need to fill out a short health questionnaire before getting a vaccination and, understandably, the form is in French.

You can see an example of the form below.

You will first be asked to give basic contact details: Your surname, first name, date of birth and social security number (if you have one). 

How to get Covid vaccine in France if no carte Vitale

Then there are seven medical questions. They are:

  1. Have you tested positive for Covid-19 (via a PCR or antigen test) in the last three months?
  2. Do you have a fever today?
  3. Have you received a vaccine in the past two weeks? If so, which one?
  4. Do you have a history of allergy or hypersensitivity to certain substances or with other vaccines?
  5. Do you have a coagulation disorder? (in particular, do you have a low blood platelet count or take anticoagulants)
  6. Are you pregnant?
  7. Are you breastfeeding?

This is the general form that will have to be filled out at vaccination centres. If you qualify for the jab due to having existing ‘at risk’ health conditions, you will need to have a consultation with your doctor first. 

Health conditions that fall into this category include:

  • Obesity (BMI > 30)
  • Chronic obstructive pulmonary disease and respiratory failure
  • Complicated arterial hypertension
  • Heart failure
  • Diabetes type 1 and 2
  • Chronic kidney failure
  • Cancers (developed under three years ago)
  • Solid organ or hematopoietic stem cell transplants
  • Down's Syndrome

France’s health authority the Haute Autorité de Santé has from March 2 recommended four new categories of health conditions. These are:

  • People with chronic liver diseases and in particular cirrhosis
  • People with psychiatric disorders
  • People with dementia
  • People with a history of having strokes

If you fall into one of these categories or have any health questions about the vaccination, you should consult your GP in advance.

Read more:

Covid France: Can I get vaccinated at my place of work?

How do I know if my GP in France has Covid vaccine doses?

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