Hesston-Adult Influenza

Please answer the following to help our pharmacists assess your eligibility for an Adult Influenza test. Note: All eligible patients will be evaluated by a pharmacist in store. The $65 fee will cover the assessment by the pharmacist. Test will be included if appropriate.
Name (First and Last)
Date of Birth

MonthDayYear
Date
Age
Phone
Email
example@example.com
Address
City
State
Zip
County
Primary Care Provider
Primary Care Provider Medication Allergies
Medication Allergies
Current Medications (Rx, OTC, herbal, topical, pain or allergy, supplements, vitamins, etc.)
Treatments tried for current condition (if none, indicate N/A)
Are you 18 years of age or older?

YesNo
Are you pregnant or breastfeeding?

YesNo
Have you ever been diagnosed with a weekend immune system (e.g. cancer, HIV/AIDS, transplant, long-term steroids, etc.)?

YesNo
If yes to above, please explain:
Do you require supplemental oxygen therapy?

YesNo
Are you a resident of a nursing home or long-term care facility, in hospice, or receiving home health services?

YesNo
Do you have a pending test for your flu-like symptoms (COVID, Strep, Flu)?

YesNo
Have you tested positive for influenza in the previous four weeks?

YesNo
When did your flu-like symptoms start?

More than two days ago2 days ago, yesterday or today
Do you have any of the following symptoms (check all that apply)?

FeverNasal CongestionMuscle/body achesCoughSore ThroatOther
If you answered "other" to above, please explain
Do you have any of the following symptoms (check all that apply)?

History of allergic reactions to influenza treatmentHistory of physiologic side effects from any previous influenza treatmentReceived FluMist or a generic equivalent within the past two weeks
Thank you! After clicking "submit" you should receive a call from us in about an hour. The pharmacist will need to review the form prior to scheduling the appointment. Thanks so much!
Should be Empty:

Thank you! After clicking "submit" you should receive a call from us in about an hour. The pharmacist will need to review the form prior to scheduling the appointment. Thanks so much!