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   
Chills   
Fever at or greater than 100 degrees Fahrenheit   
Shortness of breath/difficulty breathing   
Muscle or body aches   
Sore throat   
New loss of taste or smell Diarrhea   
Headache   
Nausea or vomiting   
New fatigue   
Congestion or runny nose   

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2. Have you or anyone in your household been tested for COVID-19?
 

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3. Have you or anyone in your family tested POSITIVE for COVID-19?
 

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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?
 

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5. Have you or anyone in your household traveled in the U.S. in the past 21 days?
 

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6. Have you or anyone in your household traveled on a cruise ship in the last 21 days?
 

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7. Are you or anyone in your household a health care provider or emergency responder?
 

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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?
 

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9. Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
 

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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?
 

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Flu vaccine screening questions:

1. Does your child have any allergies? (Foods/Medications)
 

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2. Is your child taking any medications currently?
 

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3. Does your child have a current illness/recent fever
 

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4. Does your child have an allergy to eggs or neomycin
 

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5. Has your child had a serious adverse reaction to any prior vaccine
 

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6. Has your child received a flu vaccine in the past? If so, what year?
 

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7. Has your child ever had Guillain- Barre syndrome? (a neurological condition)
 

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Signature of Patient or Guardian