• INFLUENZA Vaccine Questionnaire 2025-2026

    INFLUENZA Vaccine Questionnaire 2025-2026

  • Vaccine Questionnaire 2025-2026

    List all family members receiving vaccines today:

  • Which insurance does Patient have?

  • *If caregiver & child insurance is different, caregiver must supply insurance info or cash pay.*

    For ALL: Please ask your healthcare provider any questions. A parent must complete these questions for minors.

     

  • 1. Has the patient had a moderate/severe illness in the last 24 hours?
  • 2. Has the patient ever had a severe allergic reaction to any vaccine?
  • 3. Has the patient had Guillain-Barré syndrome?
  • 4. Has the patient had an influenza vaccine in Fall/Winter of 2025/2026?
  • 5. Would you like a paper copy of the Vaccine Information Statement?

  • For MIST ONLY (skip this if the patient is receiving a Flu injection)

     

  • 6. Has the patient received ANY vaccines in the last 4 weeks?
  • 7. Has the patient had wheezing or asthma in the last 12 months?
  • 8. Does the patient use aspirin or products containing aspirin?
  • 9. Has the patient used Tamiflu or another antiviral in the last 17 days?
  • 10. Is the patient pregnant?
  • 11. Does the patient have cerebrospinal fluid leaks?
  • 12. Does the patient have cochlear implants?
  • 13. Is the patient immunocompromised or have close contacts who are?
  • 14. Does the patient have any spleen issues or sickle cell disease?

  • Comments for any "yes" answers above:

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  • COVID-19 Vaccine Questionnaire 2025-2026

  • Please ask your healthcare provider any questions. A parent must complete these questions for minors.

  • 1. Has the patient had an actual COVID infection in the last 90 days?
  • 2. Has the patient had a severe allergic reaction to the COVID vaccine?
  • 3. Has the child ever been diagnosed with a heart condition or had Multisystem Inflammatory Syndrome (MIS-C) after COVID-19 infection?
  • 4. Is the patient immunocompromised?
  • 5. Would you like a copy of the COVID vaccine VIS fact sheet?

  • CONSENT FOR VACCINATION: I have read, had explained to me, or declined the Vaccine Information Statement for the(se) vaccine(s I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) requested and ask that the vaccine(s) be given to the person named above. I, on behalf of myself, my heirs, executors, and personal representatives hereby agree to release, indemnify, and hold harmless Tosa Pediatrics, its subsidiaries, affiliates, agents, owners, providers, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine. 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.

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