Immunization Consent Form Full Name * Birth Date * Age Sex MaleFemale Address * City * State Option 1Option 2Option 3 Zip * Phone Medicare ID Primary Care Physician Dr. Phone Number The following questions will help us better determine which vaccines you are eligible for: Do you feel sick today? YesNoDon't know If yes, Do you have a new fever, cough, diarrhea and/or vomiting? Do you have allergies to latex, medications, food, or vaccines? (Example eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, or thimerosal) YesNoDon't know If yes, please list Have you ever had a reaction after receiving a vaccination? YesNoDon't know Have you ever fainted or felt dizzy after receiving a vaccine? YesNoDon't know Have you received any vaccinations or skin tests in the past four weeks? YesNoDon't know If yes, please list. Do you have a long term health problem with heart disease, lung disease, asthma, kidney disease, neurologic or neuromuscular disease, liver disease, metabolic disease (e.g., diabetes), or anemia or another blood disorder? YesNoDon't Know Have you ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain- Barre syndrome or other nervous system problems? YesNoDon't Know For women: Are you pregnant or is there a chance you could become pregnant during the next month? YesNoDon't Know Do you have a weakened immune system because of HIV/AIDS or another disease that affects the immune system, long-term treatment with drugs such as high-dose steroids, or cancer treatment with radiation or drugs? YesNoDon't Know Are you currently on home infusions or weekly injections (such as Remicade, Humira, Enbrel, Cimzia, Simponi, Simponi Aria, Xelijanz, Orencia, Arava, Actermra, Cytoxan, Rituxan, adalimumab, infliximab, or etanercept), high dose methotrexate, azathioprineor YesNoDon't Know Do you live with or expect to be in close contact with anyone who has a severely weakened immune system? YesNoDon't Know Are you currently taking high dose steroid therapy (prednisone >20mg.day or equivalent) for longer than two weeks? YesNoDon't Know During the past year, have you received a transfusion of blood, blood products including antibodies or been given immune (gamma) globulin? YesNoDon't Know Verification Please enter any two digits *Example: 12 This box is for spam protection - <strong>please leave it blank</strong>:
