Flu Shot Screening Questionnaire | Rastin's Wilson St. Pharmacy

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Screening Questionnaire for Inactivated Injectable Influenza Vaccine 2020-2021

Step 1 of 3

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Section 1: Personal Information
Patient First and Last Name:*
Patient Telephone:*
Patient Address:*
Patient OHIP No:*
Gender*
- Male
- Female
Age*
Child’s Weight (kg or lb)
Date of Birth (MM/DD/YYYY)
Name of Emergency Contact*
Contact’s Daytime Phone Number*
Emergency Contact’s Relationship to Patient*
Contact’s Evening/Other Phone Number*

Section 2: COVID-19 Screening
Note: Every individual who will be present during the administration of the vaccine (regardless of whether you are receiving a vaccine or not) should be screened for COVID-19.
Have you travelled outside of Canada in the past 14 days?*
- Yes
- No
Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate personal protective equipment?*
- Yes
- No
Are you experiencing any of the following symptoms?*
Fever • New onset of cough
• Worsening chronic cough
• Shortness of breath
• Difficulty breathing
• Sore throat
• Difficulty swallowing
• New or unusual worsening of chronic conditions
• Low blood pressure for your age
• Decrease or loss of sense of taste or smell
• Chills
• Headaches
• Unexplained fatigue/lethargy/malaise/muscle aches (myalgias)
• Nausea/vomiting, diarrhea, abdominal pain
• Pink eye (conjunctivitis)
• Runny nose or nasal congestion without other known cause
• Fast heart rate
• For infants and young children: decreased or lack of appetite/difficulty feeding
- Yes
- No
If you are older than 70 years of age, are you experiencing any of the following symptoms?
• Delirium
• Unexplained or increased number of falls
• Acute functional decline
- Yes
- No
If you respond YES to ANY of the screening questions in Section 2, you should not receive a flu shot at the pharmacy at this time and should speak with your pharmacist.

If the responses to ALL of the screening questions in Section 2 are NO, proceed to Section 3.

Section 3: Screening Questionnaire
For adult patients as well as parents of children (≥ 5 years of age) to be vaccinated:

The following questions will help us determine if there is any reason you or your child should not get the flu shot today. If you answer “yes” to any question, it does not necessarily mean the shot cannot be given. It simply means additional questions must be asked.

If a question is not clear, please ask your pharmacist to explain it.
Are you sick today? (fever greater than 39.5°C, breathing problems, or active infection)*
- Yes
- No
- Unsure
If YES, do NOT get the shot today
Are you allergic to any medications including vaccines?*
- Yes
- No
- Unsure
If YES, your pharmacist can check whether the flu shot contains any of these potential allergens and use one which does not.
Are you allergic to any of the following?*
- Thimerosal
- Egg protein
- No
If YES, your pharmacist can check whether the flu shot contains any of these potential allergens and use one which does not.
Are you allergic to any part of the flu shot, or have you had a severe, life-threatening allergic reaction to a past flu shot?*
- Yes
- No
- Unsure
If YES, or UNSURE, do NOT get the shot & SPEAK WITH YOUR MD
Have you had wheezing, chest tightness or difficulty breathing within 24 hours of getting a flu shot?*
- Yes
- No
- Unsure
If YES, or UNSURE, do NOT get the shot & SPEAK WITH YOUR MD
Have you had a reaction to eggs or egg products?*
- Yes
- No
- Unsure
If YES, or UNSURE, speak to the pharmacist, you may be able to receive the flu shot but may require a longer observation period post-administration.
Do you have any serious allergy to latex or natural rubber?*
- Yes
- No
- Unsure
If YES, or UNSURE, you can receive the flu shot but nonlatex materials are to be used
Have you had Guillain-Barré Syndrome within 6 weeks of getting a flu shot?*
- Yes
- No
- Unsure
If YES, do not get the flu shot and SPEAK WITH YOUR MD
Do you have a new or changing neurological disorder?*
- Yes
- No
- Unsure
If YES, do not get the flu shot and SPEAK WITH YOUR MD
Do you have bleeding problems or use blood thinners? (e.g. warfarin, low dose or regular strength aspirin)*
- Yes
- No
- Unsure
If YES, shot can be given but apply gentle pressure afterwards
Section 4: Consent Given By Patient/Agent
I, the undersigned client, parent or guardian, have read or had explained to me information about the flu shot as outlined on the Flu Shot Fact Sheet. I have had the chance to ask questions, and answers were given to my satisfaction. I understand the risks and benefits of receiving the flu shot. I agree to wait in the pharmacy for 15 minutes (or time recommended by the pharmacist) after getting the flu shot.

I am aware that it is possible (yet rare) to have an extreme allergic reaction to any component of the vaccine. Some serious reactions called “anaphylaxis” can be life-threatening and is a medical emergency. If I experience such a reaction following vaccination, I am aware that it may require the administration of epinephrine, diphenhydramine, beta-agonists, and/or antihistamines to try to treat this reaction and that 9-1-1 will be called to provide additional assistance to the immunizer. The symptoms of an anaphylactic reaction may include hives, difficulty breathing, swelling of the tongue, throat, and/or lips.

In the event of anaphylaxis, I will receive a copy of this form containing information on emergency treatments that I had received, or a copy will be provided to my agent or EMS paramedics.
Choose one of the following*
- I confirm that I want to receive the seasonal influenza vaccine
- I confirm that I want my child to receive the seasonal influenza vaccine
Patient/Agent Name (& Relationship)*
Patient/Agent Signature*
Date Signed (MM/DD/YYYY)*

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