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Vaccination Screening Form
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*
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Forename
*
Surname
*
Date of Birth
*
Day
Month
Year
Gender
Age
Please enter a number from
0
to
150
.
Address
GP Name
GP Address
Phone Number
*
Mobile Number
*
Email Address
*
Emergency Contact Name
Emergency Contact Number
*
Do you have any allergies?
*
Yes
No
Indicate which allergy you suffer from
*
Egg
Latex
Other
Please provide the details of your egg allergy.
*
Have you had a severe reaction to egg that required intensive care?
*
Yes
No
Please provide details
*
Please provide the details of your Latex allergy.
*
Please provide the details of other allergies.
*
Have you ever had an allergic or anaphylactic reaction to a vaccine before?
*
Yes
No
Please provide details
*
Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)?
*
Yes
No
Please provide details
*
Are you currently taking any medication (over the counter or prescription)?
Yes
No
Please list all medications
*
Please tick if any of the below clinical risk groups apply:
Chronic respiratory disease
Chronic liver disease
Chronic heart disease
Diabetes
Chronic renal disease
BMI 40 or above
Immunosuppression
Asplenia or dysfunction of the spleen
Chronic neurological disease(excluding stroke/transient ischaemic attack)
None of the above
Please provide the details about the risk groups selected
Have you already had a flu vaccine for this flu season?
Yes
No
Have you received the flu vaccine before for another flu season?
Yes
No
NHS eligibility, please tick if any of the following apply:
Carer
Social care worker
Hospice worker
Close contact of an immunocompromised person
Person in a long-stay residential home
None of the above
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