STOP! CONSULT WITH MEDICAL STAFF
BEFORE RECEIVING THIS VACCINE.
 
 
Thank you for submitting your medication form. Unfortunately, your answers indicate that you may not be able receive any of the medications that are currently available. Please contact your health care provider or your local health department for additional information.
Demographic Information
 First Name: Telephone:
 Last Name: DOB:
 Address: Age:
 Address2: Sex:
 City, St Zip: Email:
Health History Information
1. Has this person had a serious reaction to the flu vaccine in the past?
1a. Person had cardiac arrest, collapsed or called 911 after getting vaccine?
2. Does this person have an allergy to eggs or egg products?
2a. Has this person had a reaction to eggs involving symptoms other than hives, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention?
3. Has this person ever had Guillain-Barre Syndrome (GBS)?
3a. Person had a history of GBS within six weeks after having a flu vaccination?
4. Is this person allergic to Thimerosal or mercury products?
4a. Person experienced respiratory distress or collapsed using Thimerosal products?
 
I, the undersigned, certify that all of the above information is correct to the best of my knowledge. I hereby authorize the recipient of this document to share this information with public health entities at the local, state and federal level for purposes of ensuring medication efficacy and safety.  I have been offered a copy of Notice of Information Practices.
Client Signature:_____________________________________Date Signed:________________
 
Clinician Use Only:
Vaccine Provided:  IM  Nasal  ID
 
 Place Lot # Sticker Here Location: (R) (L) (Deltoid) (VL)
 
Clinic Site:____________________________________
 
 
Vaccinator's Signature:______________________    Date:_____________
 
Fact sheet: Vaccine Information Statements