Flu Shot Questionnaire
Your Name
First Name
Last Name
Last Name
For organizational purposes
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which Vaccine would you like today?
65 and up quadrivalent high dose
65 and younger quadrivalent
Are you sick today?
Yes
No
Do you have allergies to food (egg protein), medications, or any vaccine?
Yes
No
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease, (e.g., diabetes), anemia, or other blood disorder?
Yes
No
Do you have cancer, leukemia, Aids, or any other immune system problem?
Yes
No
Do you take cortisone, prednisone, other steroids, anticancer drugs, or have you had any x-ray treatments?
Yes
No
During the past year, have you received a transfusion of blood, blood products, or have been given a medicine called immune (gamma) globulin?
Yes
No
For women: Are you pregnant or is there a chance you could become pregnant during the next 3 months?
Yes
No
Will you have direct contact with an infant younger than 12 months old in the next few days?
Yes
No
Have you received any vaccines within the past 4 weeks?
Yes
No
Name of Parent or Person Receiving Vaccine
First Name
Last Name
Signature or Parents Signature
Clear
Date Signed
-
Month
-
Day
Year
Date
Primary Care Physician:
Internal use only below
Vaccine Administered
Pharmacist Name:
Lot #
Expiration Date:
Injection site:
Date on VIS: 8/6/21
VIS given: YES
Submit
Should be Empty: