Immunization Consent Form - Delta Pharmacy printable pdf download

IMMUNIZATION CONSENT FORM

NAME: ____________________________________________ BIRTH DATE: ____/____/____ AGE:_______ SEX: M / F_____

ADDRESS:_________________________________________ CITY:_________________________STATE: ____ZIP:_________

PHONE: (_____) _______________

MEDICARE ID: ________________________

PRIMARY CARE PHYSICIAN: ________________________________ Dr. PHONE NUMBER: ___________________________

The following questions will help us better determine which vaccines you are

DON’T

YES NO

eligible for:

KNOW

1. Do you feel sick today?

If yes: (Do you have a new fever, cough, diarrhea and/or vomiting?)

2. Do you have allergies to latex, medications, food, or vaccines? (Example

eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol,

yeast, or thimerosal)

If yes, please list:

3. Have you ever had a reaction after receiving a vaccination?

4. Have you ever fainted or felt dizzy after receiving a vaccine?

5. Have you received any vaccinations or skin tests in the past four weeks?

If yes, please list:

6. Do you have a long term health problem with heart disease, lung disease,

asthma, kidney disease, neurologic or neuromuscular disease, liver

disease, metabolic disease (e.g., diabetes), or anemia or another blood

disorder?

7. Have you ever had a seizure disorder for which you are on seizure

medications, a brain disorder, Guillain- Barre syndrome or other nervous

system problems?

8. For women: Are you pregnant or is there a chance you could become

pregnant during the next month?

9. Do you have a weakened immune system because of HIV/AIDS or another

disease that affects the immune system, long-term treatment with drugs

such as high-dose steroids, or cancer treatment with radiation or drugs?

10. Are you currently on home infusions or weekly injections (such as

Remicade, Humira, Enbrel, Cimzia, Simponi, Simponi Aria, Xelijanz,

Orencia, Arava, Actermra, Cytoxan, Rituxan, adalimumab, infliximab, or

etanercept), high dose methotrexate, azathioprineor 6- mercaptopurine,

antivirals, anticancer drugs or radiation treatment?

11. Do you live with or expect to be in close contact with anyone who has a

severely weakened immune system?

12. Are you currently taking high dose steroid therapy (prednisone >20mg.day

or equivalent) for longer than two weeks?

13. During the past year, have you received a transfusion of blood, blood

products including antibodies or been given immune (gamma) globulin?

Revised 12/2/2015

Immunization Consent Form - Delta Pharmacy

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