Flu Immunization Questionnaire

Childs Name

Childs DOB

1. Is your child allergic to eggs?

Yes No

a. If yes, please describe the reaction.

2. Is your child allergic to latex product?

Yes No

a. If yes, please describe the reaction.

3. Does your child have a history of Asthma?

Yes No

Please check with your clinical staff person or physician if you have any questions regarding this question.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent/Guardian Signature

Date

FOR OFFICE STAFF ONLY

Temp

Manufacturer

Lot #

Expiration

Route

Site

Lot #

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