Flumist Vaccination
Date: ___‐____‐____ Assessment, Release & Consent Form
Name: ________________________________ DOB:______‐______‐______ Age:___________ Sex: M / F (Circle One)
Address: ____________________________________________ City:__________________ State:_____ Zip:__________
Phone #_______‐______‐__________
Please have ALL OF YOUR INSURANCE CARDS out and ready for a Kohll’s employee to copy and attach to this form.
Primary Insurance:_________________________________ Policy #________________________Group #____________
FluMist should only be administered to healthy persons ages 2‐49 years old. Certain people must not receive the
FluMist. You must answer each question below, and have the answers reviewed by a health care professional to ensure
you are eligible to receive FluMist. The health care professional will keep this questionnaire and any information
collected in a confidential manner.
PLEASE CIRCLE THE ANSWERS TO THE FOLLOWING QUESTIONS:
1. Have you ever had a severe reaction to any vaccine? YES NO
2. Are you allergic to eggs, arginine, gelatin or gentamicin?
YES NO
3. Do you have any problems with your immune system?
YES N O
4. Do you have AIDS, HIV, cancer or have you received an organ transplant?
YES NO
5. Did a doctor ever tell you that you had asthma or reactive airway disease?
YES NO
6. Do you have any diseases of the lungs, including chronic bronchitis,
emphysema, or cystic fibrosis?
YES NO
7. Did you ever have Guillain‐Barre syndrome or active neurological disease?
YES NO
8. Do you have kidney disease?
YES NO
9. Do you have a heart disease (angina, congestive heart failure) or have you
ever had a heart attack or stroke?
YES
NO
10. Do you have a blood disease like sickle cell disease or thalassemia?
YES
NO
11. Do you currently have a cold or other respiratory illness or a fever?
YES
NO
12. Have you received any vaccines within the last month or do you plan to
receive any within the next month?
YES
NO
13. Are you taking any prescription medicines to prevent or treat the flu?
YES
NO
14. Does anyone living with you have a compromised immune system?
YES
NO
15. Do you have diabetes or other metabolic disease?
YES
NO
16. Are you less than 17 years of age and taking aspirin?
YES
NO
17. Women: Are you pregnant or nursing?
YES NO
I have read the above information or have had the information explained to me. I have had a chance to ask questions and these
have been answered to my satisfaction. I understand the benefits and the risks of the FluMist vaccine and ask that the vaccine is
given to me, or to the person named above for whom I am authorized to make this request. I accept responsibility for seeking
medical attention for any problems with this vaccination. If for any reason my insurance does not pay for the vaccination, I
agree to pay the full amount of the procedure.
Signature____________________________________________________________Date________/_________/___________
To be completed by store personnel:
Insurance Card Copied?______ Paid Cash:______ Store Location: _________ V.I.S. 8/19/14
Intranasal Initials__________