Web IZ: ____________ ROOKS COUNTY HEALTH DEPARTMENT Grade:_ ______

Call: ______ SEASONAL INFLUENZA VACCINE ADMINISTRATION RECORD

PATIENT INFORMATION
Name Age DOB Sex: Male (Last) (First) (Middle Initial) Female Mailing Address City State Zip Code Phone Number Doctor I have been given a copy and have read, or had explained to me, the information in the “Vaccine Information Statement” and ask that the vaccine(s) indicated INFLUENZA PNEUMOCOCCAL be given to me or to the person named for whom I am authorized to make this request. The Rooks County Health Department may release my medical information to my insurance provider as necessary to receive payment. I also acknowledge that I have received or been offered a copy of the Rooks County Health Department’s Notice of Privacy Practices with the effective date of April 14, 2003.
HEALTH SCREENING
Are you currently experiencing symptoms of illness? Symptoms:	Yes or No
Is this your first flu shot?	Yes or No
Are you allergic to eggs?	Yes or No
Have you had a serious reaction to a previous dose of the influenza vaccine?	Yes or No
Do you have a history of Guillain-Barre Syndrome (GBS)?	Yes or No
Are you pregnant? months	Yes or No
Medicare Part B: ID# Name as printed on Card Medicaid /19 or 21/ Aetna, United Health or Sunflower: ID# BCBS: ID# Group# Name of Policy Holder Relationship to Insured: Self Spouse Child Other Employer: has contracted with Rooks County Health Department for my Flu Shot. No Health Insurance coverage. Paid by : Cash Check Recipient/Parent/Guardian Signature: Date *********************************HEALTH DEPARTMENT USE ONLY****************************
Vaccine	Mfg: Sanofi Exp: Lot #: Inj. Site: L R Delt / Vas Lat
(check if given) Vaccine: Pneumococcal	Mfg: Exp: _________ Lot #: ___________ Inj. Site: L R Delt / Vas Lat

Nurse Signature: ___________________________________	Date: ___________________

Temp:_________________ Weight: _____________________