INFORMATION AND INFLUENZA VACCINE ADMINISTRATION RECORD

N:\Disease Prevention\Influenza\Forms 2019 - 2020\Flu Clinic VAR.docx

Today’s Date:

Last Name: First Name: MI:

Date of Birth: Age: Gender (Check): Male Female

Mailing Address: City State ZIP

Phone (Home/Cell):

VACCINE SCREENING QUESTIONS

Please check ‘YES’ or ‘NO’ to the following questions

YES NO

Does the patient have a fever or feel sick today?

Does the patient have allergies to medicines, food, latex or vaccines?

Has the patient had an adverse reaction to vaccines?

Has the patient had a seizure or brain problem?

Does the patient have Leukemia, AIDS or other immune system problems?

Does the patient have heart disease, lung disease, kidney disease, diabetes, asthma, anemia or other long term condition?

Has the patient taken Cortisone, Prednisone, other steroids or cancer treatments in the past 3 months?

Has the patient received blood, blood products or immune globulin (IG) in the past year?

Is the patient pregnant or planning to become pregnant?

Has the patient received vaccines in the past month?

Has the patient ever fainted after injections?

Signature Date

Relationship: Self Parent Grandparent Guardian

BELOW IS FOR PERSONNEL ADMINISTERING VACCINE

DOSE (ML) VACCINE BRAND NAME

MANUFACTOR LOT

NUMBER EXPIRATION SITE/ROUTE

VIS DATE

DATE VIS GIVEN

0.5 Influenza Fluzone 8/15/19

Vaccine Administrator Signature & Title: ________________________________________ Date: ___________