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Microsoft word - flumist nasal questionnaire 2013-2014.doc
Seasonal Influenza Immunization Questionnaire
Live, Attenuated (Nasal Administration) FLUMIST
Available for healthy patients, 2 years through 49 years of age
For patients: The following questions will help us determine if you are eligible to receive influenza vaccine today. Please answer these questions by checking the boxes. If the question is not clear, please ask us to explain it. Patient Name ________________________________________ Date of Birth _______________
Address ____________________________________________ Age (years) _______________
City __________________ State ______ Zip Code ___________ Phone ___________________
Physician Name ________________________________________ Phone __________________
Do you have a cold, respiratory illness or a fever today?
Have you received any vaccinations within the past month or do you plan on getting any in
Are you taking any antiviral medications (Tamiflu, Relenza, amantadine)?
Do you have a severe allergy to eggs or egg products?
Have you had a serious reaction after receiving a vaccination?
Do you have any problems with your immune system (including HIV, AIDS, cancer, organ
Are you living with or in close contact with anyone with a weakened immune system?
Are you taking corticosteroids or anti-cancer drugs or have had x-ray treatments?
Are you taking aspirin or salicylates on a regular basis? (children & adolescents only)
Do you have lung problems (including asthma, emphysema, bronchitis, cystic fibrosis,
Do you have heart disease or past heart attack or stroke?
Do you have a history of Guillain-Barre Syndrome or active neurological disease?
Do you have any blood diseases or kidney disease?
Do you have diabetes or other metabolic disease?
Are you pregnant? (females only)
Consent for immunization:
As the patient, (or parent or guardian of minor patient), I have read the Vaccine Information Statement (7/26/13 version) and understand the benefits and risks of
receiving influenza vaccine. I have discussed the above questionnaire with the representative from Ostroms and qualify for immunization. I hereby request the
certified representative of Ostroms Drugs to administer influenza vaccine to me (or my minor) today. DSHS recipients: I understand that Ostroms does not
bill DSHS for this service and I understand that I cannot submit billing directly.
Private insurance patients: I understand that Ostroms does not bil al
insurance companies for this service but I can submit receipts directly, although there is no guarantee of payment. I wil not hold Ostroms, its personnel or
supervising physician liable for any adverse effects resulting from administration of this vaccine. Medicare Authorization To Bill:
I understand that I am giving Ostrom Drugs permission to ask Medicare for payments for my immunization administration. Medicare needs
information about me and my medical condition to make a decision about these payments. I give permission for that information to go to Medicare and the companies that handle Medicare payments requests. The Centers for Medicare and Medicaid Services (CMS) is the government’s Medicare agency. A photocopy of this release is as valid as the original document. I am responsible for paying any deductible or co-insurance copays. Therefore, I ask that payment of authorized Medicare be made on my behalf to Ostrom Drugs for immunization administration services. I authorize Ostroms to release medical information to CMS as needed to determine these benefits and related services. ______________________________________________________________________
Admin By WB _____ CP _____ GG _____ AB _____
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