Date of Birth
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Medical History Questions
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Is this your first flu vaccination? |
Yes No |
Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to latex? |
Yes No |
Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to chicken eggs, egg products, neomycin, gelatin or yeast? |
Yes No
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Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to thimerosal, which is found as a preservative in contact lens solution and some vaccines? |
Yes No |
Do you have any history of Guillain-Barre Syndrome or paralysis? |
Yes No |
Are you pregnant or breast feeding? |
Yes No |
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Based on your medical history, a nurse consultation will be provided at your scheduled appointment to further evaluate whether you are a candidate for some or all of the selected service(s).
Please note that the outcome of that consultation may result in not receiving the service(s).
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