Seasonal Influenza Vaccine Program - Adult Form (19 And Older)
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ADULT FORM (19 and older) Office Use only: Client ID#______________
Macomb County Health Department Seasonal Influenza Vaccine Program
Date:___________________
Birthdate: ________________ Social Security #: _________________________ Medicare #: _________________________
Legal Name: __________________________________________________________________________________________
(Last Name)
(First Name)
(Middle Name)
Street Address: _____________________________City:____________ State:________ Zip: _______ County:____________
Telephone #____________________________________
Sex (Circle One): Male
Female
Are you enrolled in any of the following?(
____ Medicare Part B
____ Medicaid
____ No Medical Insurance
check all that apply)
____ Commercial Insurance that does cover immunizations (circle)
____________
BCBS OF MICHIGAN
BCN
HAP
MCLAREN
OTHER
____ Commercial Insurance that does not cover immunizations_____________________________________________________________
THIS SECTION TO BE COMPLETED ONLY BY VALID MEDICARE PART B CARD HOLDERS AND COMMERCIAL INSURANCES
ACCEPTED BY MACOMB COUNTY HEALTH DEPARTMENT:
I authorize any holder of medical information about me to release to Medicare and/or my commercial insurance or their Intermediaries or
carriers, information needed for this claim. I permit a copy of this authorization to be used in place of the original, and request payment of
medical insurance benefits to the party who accepts assignment below.
X
Signature
________________________________________________
Macomb County Health Department Accepts Assignment
Medical Screening Questionnaire and Consent for Vaccination
(Use for Community Outreach Settings only)
Please circle the answer to the following questions about you or the person to be vaccinated:
Medical Screener:
____________(initials/3 digit ID)
1. Have you ever had a serious reaction to a vaccine?
YES
NO
(Include MCHD Staff 3 digit ID)
2. Are you allergic to eggs, Thimerosal, gelatin, or any antibiotics?
YES
NO
□ Denied Reason:
3. Have you received an influenza vaccination before?
YES
NO
______________________
4. Have you ever had Guillain-Barré Syndrome (GBS)?
YES
NO
5. Do you have any long-term health problem such as heart or lung disease, kidney disease or
YES
NO
metabolic disease (diabetes)?
6. Are you a current smoker?
YES
NO
7. Do you have severe thrombocytopenia (low platelet count) or a bleeding disorder?
YES
NO
8. Are you currently ill or running a fever?
YES
NO
9. Do you have asthma or have you had a recent episode of wheezing in the past 12 months?
YES
NO
10. Are you or do you think you may be pregnant?
YES
NO
11. Have you received any vaccine within the past 30 days?
YES
NO
12. Do you have cancer, leukemia, lymphoma, or any immune deficiency disease (inability to
YES
NO
fight infection) or are you currently receiving chemotherapy, radiation therapy or steroid
therapy (prednisone or cortisone)?
13. Do you have close contact with anyone who has a severely weakened immune system (for
YES
NO
example, an individual who has had a bone marrow transplant and is currently in a hospital
isolation room)?
I have read or have had explained to me, the information contained in the Vaccine Information Statement(s)
regarding the vaccine(s) to be administered today. I have had a chance to ask questions which were answered to
my satisfaction. I believe I understand the benefits and risks of the specific vaccine(s). I ask that the vaccine(s) be
given to me, or to the person for whom I am authorized to make this request. I also authorize the Macomb County
Health Department to release my immunization record information, or the immunization record information of the
person for whom I am authorized to make this request to other health care provider(s) as needed.
Macomb County Health Department Notice of Health Information Practices
I have received a copy of Macomb County Health Department’s Notice of Health Information Practices.
I understand that my acknowledgement of the Notice is evidenced by my signature on this document.
The Department is required to abide by the terms of this privacy notice. The Department may change the terms of
its notice at any time. The new notice will be effective for all protected health information that it maintains at that
time. Upon my request, the Department will provide me with the revised notice of privacy practices.
X
____________________________
______________________________
SIGNATURE of Client/Legal Guardian
PRINT NAME of Legal Guardian (if applicable)
_____Received Notice of Health Information Practices
______REFUSED written acknowledgement
9-23-2014 Adult
C:\Documents and Settings\mswiat\My Docume
nts\Downloads\ADULTVaccineRegFLUForm 2014.doc
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