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 2022 Vaccination Screening Questionnaire for Influenza Clinic
 2022 Vaccination Screening Questionnaire for Influenza Clinic
Hi there, please complete this form so we can safely give your child vaccinations. If you have more than one child, please complete a form for each child.
21Questions
 2022 Vaccination Screening Questionnaire for Influenza Clinic
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    Pick a Date
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  • 8

    If yes, what kind of reaction?            
    Did your child require epinephrine (epi-pen)?               

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  • 11

    If yes, what is the health problem?       

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  • 21
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