Flu Vaccine Questionnaire Form, Flu Vaccine Form Fill Online Printable Fillable Blank Pdffiller

Do you currentlyfeel sick or have a fever.

Japanese encephalitis vaccine name. Flu vaccine survey question title 1. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past. Adult screening and immunization documentation form seasonal influenza vaccination program last name.

Tylenol or ibuprofen eg. On this page members will find forms and resources eg screening questionnaires consent forms promotional material to help plan and administer their fall flu shot program in addition to tools and checklists to assist them in properly preparing for cold chain inspections. I the undersigned have read or had explained to me the vaccine information sheet vis.

Have you ever had a serious reaction to a previous dose of flu vaccine. If yes please list. Adult pediatric mother father health care worker physician pharmacist nurse technician rehabilitation staff question title.

Limited the established benefits of influenza vaccination for the majority of persons who have a history of gbs and who are at high risk for severe complications from influenza justify yearly vaccination. Do you have other serious allergies. Information for health professionals about the screening questionnaire for inactivated injectable influenza vaccination.

I understand the risks and benefits associated with the influenza vaccine and have had any questions satisfactorily answered. Mom dad child 3 forms completed and submitted prior to appointment time and date getting scheduled. You cannot get the flu from the inactivated influenza vaccine because it contains killed influenza viruses that cannot cause infection.

Vaccine screening questionnaire yes no did you receive the seasonal influenza vaccine last year. Flu vaccine form patient name. For the 20202021 influenza season no vaccine or packaging contains latex.

First name circle answers to questions 1 11. Do you have a fever or are you feeling ill today. Have you ever had a serious reaction to a flu vaccine such as hives or anaphylaxis.

Aspirin should not be given to anyone under 18 years of age due to the risk of reye syndrome. Patients reporting a serious reaction to a previous dose of inactivated influenza vaccine should be asked to describe their symptoms. Do you have a serious allergy to eggs.