Influenza Vaccine Questionnaire

Influenza Vaccine Questionnaire 2024-2025
Last Name
First Name
DOB
Primary Care Doctor
Childs Name if you are a parent receiving vaccine
Patient receiving the vaccine's insurance type:

CommercialMedicaid/StateHealthshareNo Health Insurance
*If parent and child's insurance is different, parent must supply their separate insurance info or cash pay*
For ALL vaccine recipients: Please answer the following questions. If the questions are unclear, please ask your healthcare provider. A parent must complete the form for children < 18 years of age.
1. Has the patient had a moderate/severe illness in the last 24 hours?

YesNoDon't know
2. Has the patient ever had a severe reaction to a flu vaccine?

YesNoDon't know
3. Has your child had a neurological illness such as Guillain-Barre' syndrome?

YesNoDon't know
4. Has the patient had an influenza vaccine this school year?

YesNoDon't know
5. Would you like a paper copy of the Vaccine Information Statement?

YesNoDon't know
STOP: Please only complete the questions below if you want to receive FluMist instead of the flu vaccine.
FLU MIST ONLY - For use in ages 2-49:
6. Has the patient received ANY vaccines in the last 4 weeks?

YesNoDon't know
7. Has the patient had wheezing or asthma in the last 12 months?

YesNoDon't know
8. Does the patient use aspirin or products containing aspirin?

YesNoDon't know
9. Has the patient used Tamiflu or other antiviral in the last 17 days?

YesNoDon't know
10. Is the patient pregnant

YesNoDon't know
11. Does the patient have cerebrospinal fluid leaks?

YesNoDon't know
12. Does the patient have close contacts who are immunocompromised?

YesNoDon't know
13. Does the patient have coclear implants?

YesNoDon't know
14. Is the patient immunocompromised?

YesNoDon't know
15. Does the patient have spleen issues or sickle cell disease?

YesNoDon't know
CONSENT FOR VACCINATION: I have read, had explained to me, or declined the Vaccine Information Statement for the vaccine (www.OCPH.info I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the influenza vaccine be given to the person named above for whom I am authorized to make this request. I understand that a record of this immunization may be shared through the Wisconsin Immunization Registry (WIR) and with other health care providers directly involved with the vaccinated person's care. A copy of this consent form is as valid as the original.
Patient/Parent Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Influenza Vaccine Questionnaire 2024-2025

*If parent and child's insurance is different, parent must supply their separate insurance info or cash pay*

If parent and child's insurance is different, parent must supply their separate insurance info or cash pay