BETHLEHEM HEALTH BUREAU

Seasonal Influenza Vaccination Consent Form

Name: _____________________________ Date of Birth: ____________ Sex:	M____ F____

Address: ___________________________________ Telephone: _____________________

City: ___________________________ State: _______________ Zip Code: ________________

Please circle YES or NO to the questions below: 1. Does the patient have a severe allergy to eggs? Yes No 2. Has the patient ever had a severe reaction to an influenza vaccine? Yes No 3. Has the patient ever had Gullian-Barre syndrome? Yes No 4. Does the patient have any other allergies? ___________________________ Yes No 5. Does the patient have asthma or recurrent or active wheezing? Yes No 6. Is the patient under 18 years of age and currently receiving aspirin or aspirin containing therapy? Yes No 7. Has the patient received either the MMR, Varicella, Yellow Fever or FluMist Vaccination in the past 30 days? Date: ______________ Yes No Does the patient have any of the following long-term health problems? Yes No (Please Circle) Heart Disease Lung Disease Kidney Disease Metabolic Diseases (eg. Diabetes) Other:___________________________________ 9. If applicable, is the patient pregnant or nursing? Yes No 10. Does the patient have close contact with anyone who has a severely weakened immune system that must be in a protective environment (e.g. An individual who has had a bone marrow transplant)? Yes No Please describe:________________________________________________ 11. Does the patient have medical insurance that covers vaccinations? Yes No

I have received and read the Centers for Disease Control and Prevention Vaccine Information Sheets dated 8/19/2014. I have no further questions at this time. I request and voluntarily consent that the seasonal influenza vaccine be given to person named above of whom I am or am the parent or legal guardian.

Signature: ____________________________________________ Date: __________________

OFFICE USE ONLY

Influenza Vaccine Given	Lot Number: _______________________	Injection Site: L / R Dosage Volume: .25ml .5ml Intranasal __________________________________________	__________________________ Signature of vaccine administrator	Date