I_R_M_C

Vaccine Documentation Consent Form

I licivt: rend 1hi:.: v;,c.:c.:inc 1nfor111;:1tion str1tc.rnenl and undt:rslir11id the inlOrn1ntion given lo ffl I request rhrit lhe vr1ccinc

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I r,ulhoiiu: rele:1cse of all ru:ords required to <>Cl on this request I n:ciucst payment of authori r:d bcncf",ts he 111>,dc lo 11<1,1C l'li)•s1c1:i11 Group/lnt..li;·

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rtcgionol rvtcdic;.il Center I clllcsl I arn enrolled in rhe insurc1nc..:c plan,nclicalt:tl ALL VJCCIYC - / I

1

Are you sick today?

2.

Have you had a fever in the last 24 hours

3.

Do you have any allergies to medications, food (i.e eggs). yeast. a vaccine component, or latex? If yes. list

-Yes No ---

Yes No

No

4. No

Have you ever had a serious reaction after receiving a vaccination?

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5. Do you have a tong-term health problem such as heart disease, lung disease, liver disease. asthma. disease, metabolic disease (e.a., diabetes), anemia, or other blood disorder

Circle which ann/v

kidney

6. Have ou had a sei2.ure or a bra,n or other nervous s stem roblem or Guillain Barre? For women, are you pregnant or is there a chance vou could become preanant during tne nexl rnontl,? 8.

Have vou received an vaccinations or TB skin lest in the east 4 weeks

9.

Do you have a history of faintinq, particularly with vaccines? 10. Have you ever received a oneumococcal, or ·-Pneumonia··. vaccine

LIVE VACCINES ONLY

1 O. Does the person to be vaccinated live wilh or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (i e bone marrow transplant recipient)? 11 Do you lake antiviral medications such as acyclovir, valacyclovir, and famciclovir ? 12. During the past year, have you received a transfusion of blood or blood products, or been given immune

(gamma) globulin or an antiviral drug?

13. In the past 3 months, have you taken medications that weaken your immune system. such as cort,sone. prednisone, other steroids, or anticancer drugs, or have you had radiation treatments? 14 Do you have cancer. leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed wilh rheumatoid arthritis. ankylosing spondylitis, Crohn's disease? Circle which apply 15. For Zoster, have you had a past reaction to gelatin or triple antibiotic ointment? I.I HepB 1.1 Hib HPV

Yes

Yes

No

No

No -·· ··-

No

No

N 0

1

Yes N 0

Yes N 0

Yes N 0

Yes N 0

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Yes N 0

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I IOTaP/DTfTdapfTd

I Influenza

Polio/lPV

1.1 HepA

Meningococcal

Rotavirus

I MMR

Tb ppd

11 PCV13

1.1 Varicella

1

1 PPV23

Other

1 i Gardasil 9

Vaccine Lot Exp Manufacturer Dose

Route

Site VIS

Date

Date Date

Given

VIS ne

.e

cci

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-

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Nurse/Medical Assistant Signature:

Patient's name

Date of Birth

Patient/Pa re nt/G ua r dia n Signature

Date

Contact this candidate