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2025 Vaccination Screening Questionnaire for Influenza Clinic

2025 Vaccination Screening Questionnaire for Influenza Clinic

Hi there, please complete this form so we can safely give your child vaccinations. If you have more than one child, please complete a form for each child.
22Questions

HIPAA

Compliance

  • 1
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  • 2
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    Pick a Date
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  • 8

    If yes, what kind of reaction?            
    Did your child require epinephrine (epi-pen)?               

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  • 9
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  • 10
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  • 11

    If yes, what is the health problem?       

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  • 12
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  • 15
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  • 21
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  • 22
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