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Flu Vaccine Screening Form

Screens each person's eligibility before the influenza shot with questions on COVID-19 exposure, pregnancy, allergies and prior reactions. It gives clinical staff a clear, signed record to decide safely who can be vaccinated.

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Full Name

Nombre

Apellido

Date of Birth

Gender

Female Male Other Prefer not to say

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

What is your job?

Where do you work?

Have you been exposed to someone diagnosed with COVID-19 in the past 14 days?

Yes No Don't know

Are you living with someone who was diagnosed with COVID-19?

Yes No Don't know

Have you been exposed to someone with suspected COVID-19 whose result is still pending?

Yes No Don't know

Are you living with someone suspected of having COVID-19 whose result is still pending?

Yes No Don't know

Have you been exposed to someone who has COVID-19 symptoms?

Yes No Don't know

Are you currently sick?

Yes No Don't know

If yes, what are you currently experiencing?

Are you pregnant?

Yes No Not applicable

Do you have allergies? If yes, please state the type of allergy and what causes it.

Did you receive a flu vaccine before?

Yes No Don't know

Did you have any threatening reaction in the past when you received a flu vaccine?

Yes No Don't know

Do you have Guillain-Barré syndrome?

Yes No Don't know

Do you have a long-term health problem? (heart, lung, kidney problems, etc.)

Yes No Don't know

Signature

Sign here

Date Signed

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