Post on 18-Jan-2021
INFORMATION AND INFLUENZA VACCINE ADMINISTRATION RECORD
N:\Disease Prevention\Influenza\Forms 2019 - 2020\Flu Clinic VAR.docx
Today’s Date:
Last Name: First Name: MI:
Date of Birth: Age: Gender (Check): Male Female
Mailing Address: City State ZIP
Phone (Home/Cell):
VACCINE SCREENING QUESTIONS
Please check ‘YES’ or ‘NO’ to the following questions
YES NO
Does the patient have a fever or feel sick today?
Does the patient have allergies to medicines, food, latex or vaccines?
Has the patient had an adverse reaction to vaccines?
Has the patient had a seizure or brain problem?
Does the patient have Leukemia, AIDS or other immune system problems?
Does the patient have heart disease, lung disease, kidney disease, diabetes, asthma, anemia or other long term condition?
Has the patient taken Cortisone, Prednisone, other steroids or cancer treatments in the past 3 months?
Has the patient received blood, blood products or immune globulin (IG) in the past year?
Is the patient pregnant or planning to become pregnant?
Has the patient received vaccines in the past month?
Has the patient ever fainted after injections?
Signature Date
Relationship: Self Parent Grandparent Guardian
BELOW IS FOR PERSONNEL ADMINISTERING VACCINE
DOSE (ML) VACCINE BRAND NAME
MANUFACTOR LOT
NUMBER EXPIRATION SITE/ROUTE
VIS DATE
DATE VIS GIVEN
0.5 Influenza Fluzone 8/15/19
Vaccine Administrator Signature & Title: ________________________________________ Date: ___________