310 E. Torrance Ave., P. O. Box 650

Pontiac, Illinois 61764

PH. 1-815-844-7174    FAX 1-815-842-2408    TDD 1-800-526-0844

Information About Person to Receive Vaccine (Please Print)

CLIENTS LEGAL NAME     LAST                              FIRST                                   MI BIRTHDATE SEX AGE
MOTHER'S MAIDEN NAME CLIENT'S SOCIAL SECURITY NUMBER PHONE #
ADDRESS CITY STATE

ZIP

  
PHYSICIAN NAME/ADDRESS

SCREENING QUESTIONNAIRE FOR IMMUNIZATIONS

YES    NO   

 

    1.  Is the client sick today?

 

   2. Does the client have allergies to medications, eggs, yeast or any vaccines?                                                     

 

  3. Has the client had a serious reaction to vaccine in the past?

 

   4.  Has the client had a seizure or a neurological problem?

 

  5. Does the client or anyone who lives with the client or takes care of the client have cancer, leukemia, AIDS, or any other immune system problem?

 

  6. Does the client or anyone who lives with the client or takes care of the client take cortisone, prednisone, other steroids, anticancer drugs or x-ray        treatments?

 

 7. Has the client received a transfusion of blood, plasma or a medicine called immune globulin in the past year?

 

 8. Is the client pregnant or at risk for becoming pregnant within the net three months?

 

  9. I received a copy of the VFC information sheets with possible side effects that could be cuased from the vaccine(s).    SHEETS GIVEN IN CLINIC ROOM

 

"I have read or have had explained to me the information in the Vaccine Information Sheet about the vaccine(s) that will be administrated. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine(s) and ask that the vaccine(s) be given to me or to the person named for whom I am authorized to make this request."

 

I authorize the release of the immunization record to my physician, the school, any early childhood program, any health care privider, or agency that may need this information.

 

  YES

   NO

 

 

Signature of person to receive vaccine or person authorized to make request.

 

         X                                                                          Date                         

     (PATIENT/PARENT/LEGAL GUARDIAN/ADULT ACCOMPANYING CHILD)

   

 DATE VFC INFORMATION SHEETS GIVEN:                           

 

VFC INFORMATION FORMS DATED: Td 10/94; DTaP 8/97; HEP B, HIB, CHICKEN POX, MMR 12/98; IPV/OPV 1/00; ROTAVIRUS 3/99; MENINGITIS 3/31/2000; HEP A 8/25/98, PREVNAR 7/18/2000