=
FLU
VACCINE QUESTIONNAIRE
Name of patient ____________________________
DOB ____________________________________
Today’s Date ______________________________
What is the Flu Vacci=
ne?
The flu vaccine is designed to reduce the risk that your child will develop=
the
strains of flu predicted to be most active during the upcoming flu season
(October-March). The CDC reco=
mmends
that all children 6-59 months receive the flu vaccine this year.
What is the purpose of
this questionnaire? The answers to these questions help us determine whether
your child can safely receive a flu vaccine.
1. Has your child had the flu vaccine
before? =
; &n=
bsp; =
; &n=
bsp; YES NO
2.&n=
bsp;
Has your child had the H1N1 vaccine before? =
&nb=
sp; =
Y=
ES NO
3. If you answered YES to question 1,=
has
your child had an adverse reaction to the flu vaccine in the past? &=
nbsp; &nbs=
p; &=
nbsp; &nbs=
p; &=
nbsp; &nbs=
p; &=
nbsp; YES NO
4. Is your child allergic to chicken
eggs? &n=
bsp; =
; &n=
bsp; =
; &n=
bsp; YES NO
5. Does your child currently have an
illness with a fever? &nbs=
p; &=
nbsp; &nbs=
p; YES NO
6. Is your child pregnant or could
possibly be pregnant? &nbs=
p; &=
nbsp; &nbs=
p; &=
nbsp;
YES NO
7. Has your child been on Steroids in=
the
past 2 weeks? =
&nb=
sp; =
YES NO
8. Has your child ever had
Guillain-Barre? &nbs=
p; &=
nbsp; &nbs=
p; &=
nbsp; &nbs=
p; YES NO
9. Have you been provided with a Flu
Vaccine Information Sheet? &nbs=
p;
=
YES NO
Signature
_____________________________________________Date___________