Influenza Vaccine Consent Form 2024

Influenza Vaccine Consent Form: What You Should Know

Do you have a current positive viral load? Yes No No response for age in question. Yes No No response for age in question. No response for any vaccines or conditions tested at baseline, prior to, or after vaccination. Do you have a current active herpes zoster? Yes No no or yes. Yes No, but do not think you have herpes zoster, which might lead to a more serious complication. Does the vaccine you have contained live viruses? Yes No or yes. Yes No, because of the risk for serious adverse reactions to live viruses that might affect your immune system. Does the vaccine you have contained any pieces of live viruses? Yes No or yes and if the vaccine contains a piece, the manufacturer advises you that you should not receive a vaccine containing another virus. See BHANGRAS (Generally Recognized as Safe). Has vaccine been prescribed to any other patient in the 12 weeks immediately prior to vaccination? Yes No No response for age in question. Yes and no Have you ever had a severe allergic reaction after vaccination? Yes No Have you taken an allergy or anaphylaxis medication in the past four hours? YES NO, not sure. YES NO NO answer for current medication use. No answer for any combination therapy. Has any of the following symptoms or signs been reported to your health care provider for the 10 weeks before vaccination during your routine health care visit? Mouth swollen and red Sore throat Chest tightness Headache Shortness of breath Coughing up blood Nasal congestion Sensation of weight gain Paresthesia of light (pins and needles) Shortness of breath or trouble breathing Dry mouth Breathing difficulty Tingling or numbness in the extremities If yes, the health care provider should refer you to a health care provider who knows about the influenza vaccine and the influenza virus:  Flu What is your health care provider supposed to do if you do not complete the form? If YES, complete the form, sign it and return to the Health and Safety Administration's PHS Information Line, toll-free at, Monday through Friday, 8 a.m.

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