FluMist Questionnaire

FluMist Questionnaire
Patient's Name *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Date
Patient's Age (Patient must be between 2-49 years old to receive FluMist) *

For information on the FluMist vaccines, click here: FluMist VIS
Parent/Guardian Signature *

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	Yes	No	Don't Know
Is the person to be vaccinated sick today?
Does the person to be vaccinated have an allergy to a component of the influenza vaccine?
Has to person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
Is the person to be vaccinated younger than age 2 years or older than age 49 years?
Does the person to be vaccinated have a long-term health problem with heart disease, lung disease (including asthma), kidney disease, neurologic disease, liver disease, or metabolic disease (e.g., diabetes)?
If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months, has a healthcare provider told you the child had wheezing or asthma?
Does the person to be vaccinated have a cochlear implant, spinal fluid leak, or no spleen; have cancer, leukemia, HIV/AIDS, or any other immune system problem; in the past 3 months, have they taken medications that affect the immune system (e.g., prednisone or other steroids, drugs for the treatment of rheumatoid arthritis, Crohn's disease, psoriasis, or anticancer drugs); or have they had radiation treatments?
Is the person to be vaccinated receiving or has recently received influenza antiviral medications?
Is the person to be vaccinated a child or teen age 6 months through 17 years and receiving aspirin or salicylate containing medicine?
Is the person to be vaccinated pregnant or could she become pregnant within the next month?
Has the person to be vaccinated ever had Guillain-Barre syndrome?
Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)?
Has the person to be vaccinated received any other vaccines in the past 4 weeks?