| Yes | No | ||
| Heart disease | |||
| Neurologic disease (epilepsy) | |||
| Diabetes Mellitus | |||
| Liver disease | |||
| Kidney disease | |||
| Cancer | |||
| Respiratory disorder (lung disease, COPD, asthma...) | |||
| Transplantation recipient | |||
| Guillain-Barre Syndrome | |||
| Anaphylactic allergies (swelling of mouth and difficulty breathing) | |||
| 3 months or more of continuous steroid use | |||
| Other (please specify) |
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