This is the flu vaccine information sheet that I made up a few years ago. It serves as a screening tool and consent form. I know my patient's medical history but I felt uncomfortable not screening parents or siblings that were not my patients who asked for a flu vaccine. Sylvia Steiger was kind enough to scan it for me and she also offered to download it on her web site. Please feel free to correct it, modify it and use it you wish. If you come up with a better one I'd love to see it. Kim Burlingham, MD --------- From: Sylvia Steiger <> To: BlindCopyReceiver:; Subject: Influenza sheet scanned Date: Monday, August 18, 1997 1:03 PM Just wanted to let you know I got the flu vaccine sheet and scanned it, and I'll post it on my web site next upload. Thanks so much! Here's the scanned version for you to post on Pedtalk -- I think it's a good piece of information! INFLUENZA VIRUS VACCINE REGISTRATION SHEET PATIENT NAME TEL # DATE 1. Is the person to be vaccinated pregnant? YES NO DON'T KNOW 2.Is the person to be vaccinated allergic to chicken eggs? YES NO DON'T KNOW 3.Is the person to be vaccinated allergic to any antibiotic other than penicillin? YES NO DON'T KNOW 4.Has the person to be vaccinated had a past history of Guillan- Barre Syndrome? YES NO DON'T KNOW 5.Has the person to be vaccinated had a fever in the last 48 hours? YES NO DON'T KNOW 6.Is the person to be vaccinated on any medications containing theophylline or warfarin? YES NO DON'T KNOW IF ANY OF THE ABOVE ANSWERS ARE "YES" OR "DON'T KNOW", PLEASE DISCUSS YOUR INFLUENZA VACCINE WITH US. VACCINE SIDE EFFECTS Side effects are not very likely in adults. Since the influenza vaccine contains only noninfectious viruses, it cannot cause influenza. Occasional cases of respiratory diseases following vaccination are a coincidence. The most frequent side effect is soreness at the injection site up to two days; this occurs in less than 1/3 of people. Other side effects include fever and muscle aches. This is more common in children and begins 6-12 hours after the vaccine ana lasts 1-2 days. Allergic reactions are extremely rare, especially if the person to be vaccinated is not allergic to eggs. Guillan-Barre Syndrome is a very rare illness causing paralysis that had at one time been associated with the influenza vaccine. In the last years careful studies have not shown an increased risk associated with this illness and the flu vaccine. Children less than 9 years old need two doses four weeks apart. I have read and understand the above information. (signature) ----------