| 1. Has this person had a serious reaction to the flu vaccine in the past? |
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| 1a. Person had cardiac arrest, collapsed or called 911 after getting vaccine? |
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| 2. Does this person have an allergy to eggs or egg products? |
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| 2a. Person eat eggs or egg products? |
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| 3. Has this person ever had Guillain-Barre Syndrome (GBS)? |
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| 3a. Person had a history of GBS within six weeks after having a flu vaccination? |
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| 4. Is this person allergic to Thimerosal or mercury products? |
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| 4a. Person experienced respiratory distress or collapsed using Thimerosal products? |
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Yo, el suscrito, certifico que toda la información anterior es correcta de acuerdo a mi conocimiento. Por la presente autorizo al receptor de este documento a compartir esta información con los organismos de salud pública al nivel local, estatal y federal con el fin de garantizar la efectividad y seguridad del medicamento. Me han ofrecido una copia de las Prácticas de Privacidad. |