Flu Shot Questionnaire
PATIENT NAME
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First Name
Last Name
DATE OF BIRTH
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Month
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Day
Year
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For patients (both children and adults) to be vaccinated: The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable influenza vaccination today. If you answer "yes" to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.
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Rows
yes
no
don't know
1. Is the person to be vaccinated sick today?
2. Does the person to be vaccinated have an allergy to a component of the vaccine?
3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
4. Has the person to be vaccinated ever had Guillain-Barré syndrome?
FORM COMPLETED BY
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Relationship to Patient
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Signature
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DATE
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