Flu Shot questionaire

Screening Checklist for Contraindications to Injectable Influenza Vaccination

VIS Date: 8/6/21
Screening Checklist
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Who is your primary care physician?
For patients (both children and adults) to be vaccinated: The following questions will help us determine if there is any reason we should not five you or your child inactivated injectable influenza vaccination today. If you answer "yes" to any questions, it does not necessarily mean you (or your child) should not be vaccinated.It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.
1. Is the person to be vaccinated sick today?*

YesNoDon't Know
2. Does the person to be vaccinated have an allergy to an ingredient to the vaccine?*

YesNoDon't know
3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?*

YesNoDon't Know
4. Has the person to be vaccinated ever had Guillain Barre syndrome?*

YesNoDon't know
5. Has the person to be vaccinated ever felt dizzy or faint before, during, or after a shot?*

YesNoDon't Know
6. Is the person to be vaccinated anxious about getting a shot today?*

YesNoDon't know
Which Arm*

Right deltoidLeft deltoid
DATE*

MonthDayYear
Date
Signature*
Should be Empty:

Screening Checklist for Contraindications to Injectable Influenza Vaccination