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Beeches Green Surgery NHS GP Surgery in Stroud

Questionnaire for unvaccinated (COVID-19) – 16 to 25s

Questionnaire for Unvaccinated (COVID-19) – 16-25s

Section

COVID-19 vaccination

Have you had a COVID-19 vaccination? *

Yes

As you have had a COVID-19 vaccine, you cannot complete this form. Please do not submit this form.

COVID-19 vaccination questions

Do you plan on being vaccinated against COVID-19?

Yes

I have not been vaccinated against COVID-19 because (please tick all relevant boxes):

I haven’t had the time

I have had difficulty accessing vaccination clinics

I don’t think the vaccine works

I am worried about the side effects of the vaccine

I am concerned over who is profiting from the vaccine

I don’t think I need the vaccine

I have already had COVID

In your own words please describe why you have not been vaccinated against COVID-19?

I have found important information about the COVID-19 vaccination via (please tick all relevant boxes):

Social media

News

Forums/blogs/websites

YouTube

Friends/Family

NHS services

Educational provider/employer

Other

Please state other:

Would you like to receive more information regarding the vaccine?

Yes

Would you like to be contacted by a medical student to discuss the COVID-19 vaccination?

Yes

If you are human, leave this field blank.

Beeches Green Surgery
Beeches Green
Stroud
Gloucestershire
GL5 4BH

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01453 763980

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