Immunization Form | Square Medical Care

YES

NO

Are you currently sick with a fever?

YES

NO

Have you ever had a life threatening allergy to any component (or part) of the flu or pneumonia vaccine?
If yes, please describe:

YES

NO

Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving flu vaccine?

YES

NO

Have you ever had a pneumonia shot?

YES

NO

Are you a smoker or have a chronic medical condition such as asthma, heart or lung disease?
If yes, please describe:

YES

NO

Have you ever had a severe life threatening allergy to eggs or egg products?

YES

NO

Are you currently pregnant?

YES

NO

Do you have a history of asthma or wheezing?

YES

NO

Are you a child or adolescent receiving long-term aspirin therapy?

YES

NO

Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care?

YES

NO

Have you received any other vaccinations within the last 4 weeks?

YES

NO

Have you taken an antiviral medication for the flu within the last 48 hours?

Influenza/ Pneumococcal Immunization Consent Form

YES NO	Are you currently sick with a fever?
YES NO	Have you ever had a life threatening allergy to any component (or part) of the flu or pneumonia vaccine? If yes, please describe:
YES NO	Have you ever developed Guillain-Barre Syndrome within 6 weeks of receiving flu vaccine?
YES NO	Have you ever had a pneumonia shot?
YES NO	Are you a smoker or have a chronic medical condition such as asthma, heart or lung disease? If yes, please describe:
YES NO	Have you ever had a severe life threatening allergy to eggs or egg products?
YES NO	Are you currently pregnant?
YES NO	Do you have a history of asthma or wheezing?
YES NO	Are you a child or adolescent receiving long-term aspirin therapy?
YES NO	Do you have a weakened immune system or have close contact with a person with an extremely weakened immune system who needs special care?
YES NO	Have you received any other vaccinations within the last 4 weeks?
YES NO	Have you taken an antiviral medication for the flu within the last 48 hours?