INFLUENZA VACCINE SCREENING QUESTIONNAIRE

Patient Name: ___________________________________________________ Gender: ________

Address: __________________________________________________________________________
Age: _______ Birth date: ___________

1. Have you received the flu vaccine before? Yes No

2. Have you had a serious allergic reaction to a past flu vaccine? Yes No

3. Are you feeling sick today? Yes No

(e.g. fever 38C, breathing problems or active infection)

4. Have you had a severe reaction to chicken, eggs or any egg products? Yes No
(e.g. wheezing, chest tightness, difficulty breathing, hives)

5. Have you had Guillain-Barré Syndrome

within 6 weeks of getting a flu vaccine? Yes No

6. Do you have a bleeding problem or use blood

thinning medications? (e.g. warfarin, Aspirin) Yes No

Form reviewed by: ______________________________

I have read and truthfully answered the questions above. I have read or have had explained to me the
information about Influenza and Influenza vaccine. I have had a chance to ask questions that were
answered to my satisfaction. I believe I understand the benefits and risks of the Influenza vaccine and I
consent that the vaccine be given to me.

_______________________________________________ _______________________

Signature over printed name Date

In the course of your availment of the vaccine, you are giving us consent to process your personal information and sensitive personal information (“personal
data”) relating to you for emergency contact information. Such processing of personal data may include its collection, recording, retrieval, use, retention, and
disposal/destruction. Personal data may include birthdate, address, contact information, medical information, medication, medical history and other
information which are relevant for the purpose of your availment of such healthcare service.