Hesston-Under 18 Flu

PATIENT INFORMATION
Name
Date of Birth

MonthDayYear
Date
Age
Legal Guardian Name
Email
example@example.com
Address
Address
City
State
Zip
County
Primary Care Provider
Medication Allergies
Current Medications (Rx, OTC, herbal, topical, pain or allergy, supplements, vitamins, etc.)
Treatments tried for current condition (if none, indicate N/A)
Please answer the following to help our pharmacists assess your eligibility for an influenza test. Note: All eligible patients will also be evaluated by a pharmacist in the store. The $65 fee will cover the assessments by the pharmacist. (Test will be included if appropriate)
Are you under 6 years of age?

YesNo
Are you pregnant or breastfeeding?

YesNo
Are you experiencing any altered mental status or change from normal cognition?

YesNo
If yes to above, please explain
Have you ever been diagnosed with a weakend immune system (e.g. cancer, HIV/AIDS, transpant, long-term steroids, etc)?

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

YesNo
Are you receiving hemodialysis?

YesNo
Do you have a history of chronic kidney disease or reduced kidney function?

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

FeverNasal CongestionMuscle/body achesCoughSore ThroatOther
Do you have any of the following?

History of allergic reactions to influenza treatmentHistory of physiologic side effects from any previous influenza treatmentReceived Flumist or 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!
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PATIENT INFORMATION

Please answer the following to help our pharmacists assess your eligibility for an influenza test. Note: All eligible patients will also be evaluated by a pharmacist in the store. The $65 fee will cover the assessments by the pharmacist. (Test will be included if appropriate)

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!