Flu Vaccination Patient Questionnaire*
To be retained in the pharmacy and filed securely Mr Mrs Miss Ms Other Male
Female
Other/NA
Date of Birth
D D / M M / Y Y Y Y
Surname: First Name: Address:
PPS Number:
Telephone Number:
Medical Card/GMS No: GP Name: GP Address:
I consent to this information being shared with my doctor: Yes
No
Medical History: Are you pregnant (intranasal vaccine is contraindicated in pregnancy)?
Yes
No
For children aged 2 to <18 years:
Have you had breast surgery?
Yes
No
Do you feel unwell in any way, temperature or infection?
Yes
No
Are you allergic to eggs or chicken?
Yes
No
Have you ever had an allergic reaction to latex?
Yes
No
Have you ever had an allergy to a previous vaccination?
Yes
No
Have you ever had an allergic reaction to previous injections including anaphylaxis?
Yes
No
Do you suffer from a bleeding disorder or are you taking anticoagulant medication such as warfarin? Yes
No
Have you any other allergies?
Yes
No
Have you any medical conditions and are you currently taking any medication?
Yes
No
Is the child aged 2 years or over?
Yes
No
If the child is aged 2 to <9 years, are they in a clinically at-risk group?
Yes
No
Is the child currently experiencing symptoms of acute asthma exacerbation?
Yes
No
Does the child live with a severely immunosuppressed person?
Yes
No
Does the child have significant immunosuppression due to disease or treatment?
Yes
No
Consent: I have read and understood the accompanying leaflet and I have been given an opportunity to speak to the pharmacist providing the vaccine. The information I have provided is correct to the best of my knowledge. The influenza vaccine will be only be offered if the Pharmacist believes it is appropriate to do so. I consent to the recording and keeping of data pertaining to this service at LloydsPharmacy: I am happy to proceed with the vaccination for Influenza.
I do not wish to receive vaccination for Influenza.
Signed:
Signed:
Date:
D D / M M / Y Y Y Y
* Where the person being administered the vaccine is under 16 years of age, a parent/guardian must sign for consent.
Date:
D D / M M / Y Y Y Y
Parent/guardian signature: Date:
D D / M M / Y Y Y Y
Flu Vaccination Pharmacist Section:
Please ensure you double-check the correct vaccine is selected with another pharmacy colleague and initial below:
Correct vaccine: Check 1
Check 2
In date:
Check 2
Check 1
through the questionnaire overleaf with each patient. Use the answers to determine whether it is suitable to Go administer for each patient. sing the laminated sheet ensure the patient has no allergies to the excipients in the brand selected and confirm U consent signature. I f the patient is eligible for vaccination, administer the vaccine and complete the form below. If the patient is not eligible for the vaccine explain the reasons why. Ensure the PCRS browser is updated as requested with all required information. Ensure the patient is provided with a PIL for the vaccine used, which will highlight symptoms and possible side-effects, and a Vaccination Record Card. Remove the patient questionnaire/pharmacist section and return the remainder of the leaflet to the patient Ask the patient to remain in store for 15 minutes for observation and document if the patient leaves before the observation time. Retain the patient questionnaire and file securely. Any ADRs should be reported to the HPRA via the online service.
Name of Vaccine: Selected by:
Checked by:
Batch No:
Expiry date:
D D / M M / Y Y Y Y
Adrenaline Auto-Injector/Product: Selected by:
Checked by:
Batch No:
Expiry date:
Vaccinated? Yes
No
D D / M M / Y Y Y Y
Vaccination site: Right arm
Pharmacist (Print)
Signature:
Pharmacist Registration No: D D / M M / Y Y Y Y Date: Patient advised to remain in store for 15 minutes? Payment Category:
:
Time: Yes
No Details:
Left arm
Intranasal