Immunization Consent Form (Page 2 of 2) in pdf

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NASAL

INFLUENZA Immunization CONSENT FORM

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Information Screening Questions for Intranasal Influenza Vaccination

1. Are you sick today?

There is no evidence that acute illness reduces vaccine efficacy or increases vaccine adverse events. Persons with an acute febrile

illness usually should not be vaccinated until their symptoms have improved. Minor illnesses with or without fever do not contraindicate

use of influenza vaccine. Do not withhold vaccination if a person is taking antibiotics.

2. Do you have an allergy to eggs or to a component of the influenza vaccine?

History of anaphylactic reaction such as hives, wheezing, or difficulty breathing, or circulatory collapse or shock (not fainting) after

eating eggs or receiving any component of the intranasal live attenuated influenza vaccine (LAIV, trade name FluMist®) is usually a

contraindication for further doses. Check the package insert for a list of the vaccine components (i.e., excipients and culture media)

used in the production of the vaccine, or go to

3. Have you ever had a serious reaction to intranasal influenza vaccine in the past?

Patients reporting a serious reaction to a previous dose of LAIV should be asked to describe their symptoms. Immediate presumably

allergic reactions are usually a contraindication to further vaccination with LAIV.

4. Is the person to be vaccinated younger than age 2 years or older than age 49 years?

LAIV is not licensed for use in persons younger than age 2 years or older than age 49 years. Based on state laws, Kroger may require

a prescription for pediatric patients.

5. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic

disease (e.g., diabetes), anemia, or other blood disorders?

Persons with any of these health conditions should not be given the LAIV, but should receive the injectable influenza vaccine instead.

6. 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 steroids, or cancer treatment with x-rays or drugs?

Persons with weakened immune systems should not be given the LAIV, but should receive the injectable influenza vaccine instead.

7. Are you taking aspirin therapy or aspirin-containing therapy?

Because of the theoretical risk of Reye’s syndrome, children and teens on aspirin therapy should not be given LAIV. Instead they

should be vaccinated with the injectable influenza vaccine.

8. Are you pregnant or could you become pregnant within the next month?

Pregnant women or women planning to become pregnant within a month should not be given LAIV. All pregnant women should,

however, be vaccinated with the injectable influenza vaccine.

9. Have you ever had Guillain-Barré syndrome?

Persons with a history of Guillain-Barré syndrome (GBS) should not be given LAIV. Although data are limited, the established benefits

of influenza vaccination with injectable influenza vaccine for the majority of persons who have a history of GBS, and who are at high

risk for severe complications from influenza, justify yearly vaccination with the injectable influenza vaccine.

10. Do you live with or expect to have close contact with a person whose immune system is severely

compromised and who must be in a protective environment?

Injectable influenza vaccine is preferred for persons who have close contact with severely immunosuppressed persons during periods

in which the immunosuppressed person requires care in a protective environment.

11. Have you received any other vaccinations in the past 4 weeks?

Persons who were given an injectable live virus vaccine (e.g., MMR, MMRV, varicella, yellow fever) in the past 4 weeks should wait 28

days before receiving LAIV. There is no reason to defer giving LAIV if they were vaccinated with an inactivated vaccine or if they have

recently received blood or other antibody-containing blood products (e.g., IG).

***********Place prescription back tag on the back of this document or store stamp with address****************

Immunization Consent Form Page 2

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