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Available Forms

Flu Quest 2020

Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination

First & Last Name

For patients (both children and adults) to be vaccinated:

The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable influenza vaccination today. If you answer ?yes? to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

First & Last Name

This questionnaire is an adaptation of the IAC Flu Questionnaire. The original can be found at www.immunize.org/catg.d/p4066.pdf ? Item #P4066 (9/19)

* Required field