Screening Questionnaire Or Seasonal And H1n1 Influenza Injectable Vaccination Form printable pdf download

Screening Questionnaire Or Seasonal And H1n1 Influenza Injectable Vaccination Form

Patient name: ______________________

Date of birth: ____/____/_____

Screening Questionnaire for

Seasonal and H1N1 Influenza Injectable Vaccination

For adult patients as well as parents of children to be vaccinated: The following questions will

help us determine if there is any reason we should not give you or your child 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.

Don’t

Yes

Know

1. Is the person to be vaccinated sick today?

2. Does the person to be vaccinated have an allergy to eggs or

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:___________________________________________ Date:_______________

Form reviewed by:____________________________________________Date:_______________

Technical content reviewed by the Centers for Disease Control and Prevention. September 2009.

Adapted by MDPH from Screening Questionnaire for Injectable Vaccination from the Immunization Action

Coalition

(9-09)--

Screening Questionnaire Or Seasonal And H1n1 Influenza Injectable Vaccination Form