Flu vaccine and COVID screening

DOB: 

1. Have you or anyone in your household had any of the following symptoms in the last 21 days: (If yes, Please check all the boxes that apply)?

Cough   Yes  No
Chills   Yes  No
Fever at or greater than 100 degrees Fahrenheit   Yes  No
Shortness of breath/difficulty breathing   Yes  No
Muscle or body aches   Yes  No
Sore throat   Yes  No

New loss of taste or smell Diarrhea   Yes  No
Headache   Yes  No
Nausea or vomiting   Yes  No
New fatigue   Yes  No
Congestion or runny nose   Yes  No

Comments

2. Have you or anyone in your household been tested for COVID-19?
 Yes  No

Comments

3. Have you or anyone in your family tested POSITIVE for COVID-19?
 Yes  No

Comments

4. Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?
 Yes  No

Comments

5. Have you or anyone in your household traveled in the U.S. in the past 21 days?
 Yes  No

Comments

6. Have you or anyone in your household traveled on a cruise ship in the last 21 days?
 Yes  No

Comments

7. Are you or anyone in your household a health care provider or emergency responder?
 Yes  No

Comments

8. Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19 in the past 21 days?
 Yes  No

Comments

9. Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
 Yes  No

Comments

10. To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19 in the past 21 days?
 Yes  No

Comments

Flu vaccine screening questions:

1. Does your child have any allergies? (Foods/Medications)
 Yes  No

Comments

2. Is your child taking any medications currently?
 Yes  No

Comments

3. Does your child have a current illness/recent fever
 Yes  No

Comments

4. Does your child have an allergy to eggs or neomycin
 Yes  No

Comments

5. Has your child had a serious adverse reaction to any prior vaccine
 Yes  No

Comments

6. Has your child received a flu vaccine in the past? If so, what year?
 Yes  No

Comments

7. Has your child ever had Guillain- Barre syndrome? (a neurological condition)
 Yes  No

Comments

Signature of Patient or Guardian