Pre-Screening Flu Shot Clinic

Patient Flu Shot Pre-Screening

NO MORE THAN 24 HOURS BEFORE YOUR FLU SHOT, please complete this form. All patients are required to complete this form. Your flu shot is subject to approval upon completion of this form.
1 - Has the patient, caregiver, or anyone in the household travelled outside the US in the past 2 weeks?

YesNo
2 - Has the patient, caregiver, or anyone in the household travelled outside of Illinois in the past 2 weeks?

YesNo
3 - Has the patient, caregiver, or anyone in the household had contact with anyone suspected to have contracted covid-19?

YesNo
4 - Has the patient, caregiver, or anyone in the household had contact with any person confirmed to have contracted covid-19?

YesNo
5 - Has the patient or caregiver currently been exposed to anyone with flu-like symptoms? (Cough, shortness of breath or fever)

YesNo
6 - Are you, caregiver, or anyone in the household currently experiencing any of the following symptoms? Please check if "yes"

FeverCoughSore throatShortness of breath, wheezing, difficulty breathingMuscle achesStomach painsVomiting or diarrheaPink/red eyesFatigue or feeling unwell
7 - Are you allergic to eggs?

YesNo
8) Do you have Guillain-Barre Syndrome?

YesNo
9) Are you receiving treatment that may affect the immune system?

YesNo
10) Are you taking blood thinners or steroids?

YesNo
By signing below, you certify that the answers above are true and that there is no information being withheld.
Patient Name*

First NameLast Name
Date of Birth
MM/DD/YYYY
Patient/Caregiver Signature

Clear
Date of Signature
MM/DD/YYYY
Should be Empty:

Patient Flu Shot Pre-Screening