Flu Vaccination Screening Questionaire

    Screening Questionaire

    For Adult / Children patients:

    The following questionnaire will help you determine if there is any reason we
    should not give you or your child inactivated inject influenza vaccination. If you
    answer “yes” to any of the questions, it does not necessarily mean that you or your child should not be vaccinated: only, additional questions shall be asked for
    verification purposes. You may ask our school nurse to explain items that are not
    clear to you.

    Name of Parent:

    Contact Number of Parent:

    Name of Student:

    Grade and Section:

    Date of Birth:

    1. Do you have allergies to medications, food, a vaccine component (eggs/chicken), or latex?
    YesNoI don't know

    2. Have you had a serious reaction after receiving influenza vaccine in the past?
    YesNoI don't know

    3. Have you had a seizure or a brain or other nervous system problem? Have you even had Guillain-Barre Syndrome?
    YesNoI don't know

    4. For women: Are you pregnant or is there a chance you could become pregnant during the next month
    YesNoI don't know

    5. Is it your first time to have a Flu Shot?
    YesNoI don't know

    Note: If your child hasn’t received any Flu vaccine, he is to complete the prescribed dosage for 2 shots. After the 1st shot, 30-day interval will be observed before giving the 2nd shot.