High Dose Flu Vaccine Screening Checklist for Adults
Appointment Date
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Name
*
First Name
Middle Name
Last Name
Date of Birth
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Month
/
Day
Year
Gender
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Please Select
Male
Female
Address
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Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email Address
*
Vaccine Screening Questions
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Rows
Yes
No
1. Are you feeling sick today?
2. Do you have allergies to medications, food, a vaccine component or latex?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have a long-term health problem with heart, lung, kidney or metabolic diseases (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?
5. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
6. Do you have a parent, brother, or sister with an immune system problem?
7. In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments?
8. Have you had a seizure or a brain or other nervous system problem?
9. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
10. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
11. Have you received any vaccinations in the past 4 weeks?
Please bring the following to your appointment; Identification Card (Drivers License/State ID/Passport), Medicare or Prescription Insurance Card.
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I have read the following agreement above
Signature of Person to Receive Vaccine & EUA /VIS
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Date Signed
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Month
/
Day
Year
Date
Submit Consent Form (required)
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