Download Flu Questionnaire

MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA
For use of this form, see requiring document. Form is not valid without Requiring Document, Issuance Date, Local Form Number, and Edition Date.
REQUIRING DOCUMENT (Title and Number)
Staff Seasonal Influenza Immunization Policy (NAVHOSPCAMLEJINST 6230.2A)
ISSUANCE DATE
LOCAL FORM TITLE (Optional)
Immunization Documentation for Influenza Vaccination
NO YES
1. Does the person to be vaccinated feel sick or have a fever today?
2. Does the person to be vaccinated have any food, medication or latex reactions?
3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?
4. Is the patient receiving the vaccine taking any prescription medications to prevent or treat influenza? Have they
taken antiviral medication in the last 48 hours?
5. Does the person to be vaccinated have a long-term health problem such as: asthma, heart disease, lung
disease, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g.,
diabetes), or a blood disorder?
6. Is the person to be vaccinated a child age 2 through 4 years old?_____ If so, in the past 12 months, has the child
had asthma, reactive airway disease, or experienced an episode of wheezing?
7. Does the person to be vaccinated have a weakened immune system because of HIV/AIDS or another disease
that affects the immune system, take long term treatment with drugs such as steroids, or cancer treatment with xrays or drugs?
8. Does the person to be vaccinated live with or expect to have close contact with a person whose immune system
is severely compromised and who must be in a protective environment (such as in a hospital room with reverse air
flow or transplant recipients)?
9. Is the person to be vaccinated receiving aspirin or aspirin-containing therapy?
10. Has the person to be vaccinated ever had Guillain-Barré syndrome?
11. Is the person to be vaccinated a child under 9 years who has never received a seasonal influenza vaccine?
12. Is the person to be vaccinated pregnant or planning to become pregnant in the next month?
13. Is the person to be vaccinated younger than 2 years or older than 49 years?
14. Has the person to be vaccinated received any other vaccinations in the past 4 weeks?
O. Above noted.
NO contraindications noted, patient may receive the Influenza vaccine.
YES contraindications noted, patient will not receive the Influenza vaccine at this time.
P. The patient/parent/legal guardian was given the required information on the vaccination that will be given today. The
patient/parent/legal guardian was informed that any person that is pregnant, HIV positive, has an immune deficiency system
disorder, receiving high dose steroid therapy, radiation therapy or chemotherapy should not receive live virus vaccines, without
first talking with their PCM. The female patients are informed that some immunizations, especially live virus vaccines, may
cause harm to an unborn child, and should be avoided if you are or may be pregnant. Some medical studies show, the use of
products containing aspirin should be avoided for at least 6 weeks after receiving immunizations, especially live virus vaccines,
to reduce the risk of Reye Syndrome.
Pediatric Patient's Sponsor's Full Name:
Address:
City, State:
____________________________________________
_______________________________
_________________
Pediatric Patient's Mother's First and Maiden Name:
Country of Residence:
Phone Number:
____________________________________________
_______________________________
_________________
PRACTITIONER'S NAME
Zip Code:
____________
Race:
____________
PRACTITIONER'S SIGNATURE
DATE
HOSPITAL OR MEDICAL FACILITY
STATUS
NAME OF PERSON BEING VACCINATED (PRINT CLEARLY BELOW):
DEPARTMENT / SERVICE
RECORDS MAINTAINED AT
____________________________________________________
SPONSOR'S NAME
SSN
10-digit DoD ID #
__ __ __ __ __ __ __ __ __ __
RELATIONSHIP TO SPONSOR
BIRTH DATE OF PERSON BEING VACCINATED: _______________
Enclosure (4)
SPONSOR’S SSN (FOR CHILD UNDER 10 YRS): __ __ __ - __ __ - __ __ __ __
TURN PAPER OVER – SIGN AND DATE ON BACK
Staff Members ONLY: The following immunization was given: (circle vaccine)
Manufacture / Lot Number /
Exp. Date
Vaccine
Dose
Site
Route
VIS
Staff Signature
PEDIATRIC Influenza
MedImmune
Exp:
SanofiPasteur
Exp:
GlaxoSmithKline (GSK)
Exp:
GlaxoSmithKline (GSK)
Exp:
bioCSL
Exp:
bioCSL
Exp:
Influenza: LAIV4 0.2ml
(FluMist) Pre- Free
Bilateral Nares
IN
Influenza: IIV4 0.25ml
(Pediatric Fluzone Syringe)
Pre-Free
LT Thigh
RT Thigh
IM
LT Arm
RT Arm
LT Thigh
RT Thigh
LT Arm
RT Arm
LT Thigh
RT Thigh
LT Arm
RT Arm
Influenza: IIV4 0.5ml
(Fluarix Syringe)
Pre-Free
Influenza: IIV4 0.5ml
(Flulaval Vial)
Contains Preservative
Influenza: IIV3 0.5ml
(Afluria Syringe) Pre-Free
Influenza: IIV3 0.5ml
(Afluria vial)
Contains Preservative
Influenza (LAIV4)
2 y/o thru 17 y/o
Influenza (IIV4)
6 mo thru 35 mo
Influenza (IIV4)
 3 y/o
Influenza (IIV4)
 3 y/o
IM
Influenza (IIV3)
 9 y/o
IM
Influenza (IIV3)
 9 y/o
Influenza (LAIV4)
18 y/o thru 49 y/o
IM
IM
LT Arm
RT Arm
(see Vaccine Algorithm: if child less than 9 y/o requires 2 doses)
ADULT Influenza
MedImmune
Exp:
bioCSL Inc
Exp:
bioCSL
Exp:
GlaxoSmithKline (GSK)
Exp:
GlaxoSmithKline (GSK)
Exp:
Influenza: LAIV4 0.2ml
(FluMist) Pre-Free
Bilateral Nares
IN
Influenza: IIV3 0.5ml
(Afluria Syringe) Pre-Free
LT Arm
RT Arm
IM
Influenza (IIV3)
 18 y/o
Influenza: IIV3 0.5ml
(Afluria vial)
Contains Preservative
Influenza: IIV4 0.5ml
(Flulaval Syringe)
Pre-Free
Influenza: IIV4 0.5ml
(Fluarix Syringe)
Pre-Free
LT Arm
RT Arm
IM
Influenza (IIV3)
 18 y/o
LT Arm
RT Arm
IM
Influenza (IIV4)
 18 y/o
LT Arm
RT Arm
IM
Influenza (IIV4)
 18 y/o
Please read and sign below:
I have read or have had explained to me the information in the 2015-16 Influenza Vaccine Information Statement (VIS). I have
also had a chance to ask questions and received answers to my satisfaction. I understand the risks and benefits of the vaccine.
I understand that failure to comply with any of the above may result in insufficient immune response or harm to myself or others.
________________________________________________________________
Patient/Parent/LegalGuardian
_________________________
Date
________________________________________________________________
Staff Member Signature/Stamp
_________________________
Date
PRACTITIONER'S NAME
PATIENT'S IDENTIFICATION: (For typed or written entries, give:
Name - last, first, middle; SSN; Sex; Date of Birth; Rank/Grade.)
NHCL 6230/5 (Rev 9-2014) Exception to NAVMED 6000/5 (09-2008)
PRACTITIONER'S SIGNATURE
DATE
HOSPITAL OR MEDICAL FACILITY
STATUS
DEPARTMENT / SERVICE
RECORDS MAINTAINED AT
SPONSOR'S NAME
SSN
RELATIONSHIP TO SPONSOR