Influenza Screening Questionnaire

Child’s Name:

Date of Birth:

Age:

This form MUST be completed BEFORE your child receives a flu vaccination.

I am requesting that my child be vaccinated with:

Flu Shot

Flu Mist

1. Is your child over 6 months of age? (for Flu Shot)

Yes No

2. Is your child 2 years old or older? (for Flu Mist)

Yes No

3. Does your child have an allergy to latex?

Yes No

4. In the previous twelve months has a health care professional told you that your child has wheezing?

Yes No

5. Does your child have any chronic pulmonary, cardiovascular, metabolic or immune disorder?

Yes No

6. Has your child ever had an allergic reaction to a prior flu vaccination?

Yes No

7. Has your child ever had an allergic reaction to eggs?

Yes No

If you answered yes to the above question did your child have:

Hives

Difficulty breathing

Wheezing

Vomiting

Dizziness

Confusion

Throat swelling

Low blood pressure

8. Has your child ever been diagnosed with Guillain-Barre syndrome?

Yes No

9. Has your child received the flu vaccine in the last two years?

Yes No

10. If applicable: Is your adolescent child pregnant?

Yes No

I have been provided with a copy of the Vaccine Information Statement. I understand the risks and benefits of this immunization and wish to proceed.

Parent/Guardian signature:

Date:

For the health care provider:

Has the patient had the MMR or Varicella vaccines in the last 4 weeks?

Yes No

Date last live vaccine administered: