2020-2021 Influenza Immunization Questionnaire

Your Name and relationship to patient *

Patient Name *

First

Last

Date of Birth *

Email *

For patients to be vaccinated: The following questions will help us determine if there is any reason we should not give you (or your child) inactivated injectable influenza vaccination today. If you answer “yes” to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it. *

Acknowledged

1. Is the person to be vaccinated sick today? *

Yes
No
Don't know

2. Does the person to be vaccinated have an allergy to a component of the vaccine? *

Yes
No
Don't know

3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? *

Yes
No
Don't know

4. Has the person to be vaccinated ever had Guillain-Barré syndrome? *

Yes
No
Don't know

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