Flu shot questionnaire

1. Name (Last, First)

2. Date of birth

3. Personal Health Number

If you answer YES to any of the questions above, you are eligible for a free flu shot. To book an appointment for a flu shot, please proceed to the following section

Please answer the COVID questionnaire above

Please read the following consent statements.

I have read the information below re: the influenza vaccine.

Common reactions to the vaccine include soreness, redness and swelling where the vaccine was given. Other symptoms can include fever, headache, aching muscles and fatigue that may last 1 to 2 days. Fewer than 1 in 20 people may have oculo-respiratory syndrome (ORS). Symptoms of ORS include red eyes, a cough and/or sore throat and/or hoarseness.
You cannot get the flu from the inactivated influenza vaccine because it contains killed influenza viruses that cannot cause infection.
Acetaminophen (e.g. Tylenol®) or ibuprofen (e.g. Advil®) can be given for fever or soreness. ASA (e.g. Aspirin®) should not be given to anyone under 18 years of age due to the risk of Reye Syndrome.
For more information on Reye Syndrome, see HealthLinkBC File #84 Reye Syndrome.
It is important to stay in the clinic for 15 minutes after getting any vaccine because there is an extremely rare possibility, less than 1 in a million, of a life-threatening allergic reaction called anaphylaxis. This may include hives, difficulty breathing, or swelling of the throat, tongue or lips. Should this reaction occur, your health care provider is prepared to treat it. Emergency treatment includes administration of epinephrine (adrenaline) and transfer by ambulance to the nearest emergency department. If symptoms develop after you leave the clinic, call 9-1-1 or the local emergency number.
It is important to always report serious or unexpected reactions to your health care provider.
Guillain-Barré Syndrome (GBS) is a rare condition that can result in weakness and paralysis of the body’s muscles. It most commonly occurs after infections. In rare cases GBS can also occur after some vaccines. GBS may be associated with influenza vaccine in about 1 per million recipients.

I confirm I do not have the following medical conditions that would preclude me from getting the vaccine

Had a life-threatening reaction to a previous dose of influenza vaccine, or any part of the vaccine (people with egg allergies can be safely immunized)
Had severe oculo-respiratory syndrome after a previous flu shot
Developed Guillain-Barré Syndrome (GBS) within 8 weeks of getting any influenza vaccine without another cause being identified
Are receiving a checkpoint inhibitor to treat cancer. This may affect when you should get the vaccine

I confirm that I have never had a life-threatening reaction to the flu vaccine.

I will wear a mask while I am waiting for my flu shot, during my flu shot and as I exit the building.

I will remain two meters apart from people outside my "bubble" while waiting for my flu shot.

I will make sure that my shoulder is easily accessible so that the doctor can do the injection safely. (See below)

The doctor will be aiming here:

I understand that this appointment will be for flu shots only and there will be no opportunities for refills or discussions of other medical matters.

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