| 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? |
|
| 2. | Does this person have an allergy to eggs or egg products? |
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| 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? |
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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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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 Privacy Practices. |