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Pregnant? Yes No
Age 65 years or older? Yes No
Diabetes? Yes No
Chronic respiratory disease (asthma only if taking regular preventative medicine) Yes No
Chronic renal disease Yes No
Cardiovascular disease Yes No
Current cancer Yes No
(excluding basal and squamous skin cancer if non invasive?)
Other conditions? (please specify) ____________________________________________________
Please answer the following, if you tick ‘YES’ to any of these, please make one of our vaccination team aware
Are you currently unwell with a high fever ? Yes No
Do you have a bleeding disorder? Yes No
Are you allergic to eggs, egg proteins, any poultry products e.g chicken feathers? Yes No
Have you ever suffered an allergic response to a vaccine in the past? Yes No
Do you, or have you ever had Gullian-Barre Syndrome? Yes No
List any known allergies: ____________________________________________________________
Please list any MEDICATIONS you are currently taking, Include those that affect the immune system, or that you have had within the last
2 months.
Informed consent: I acknowledge that the information given above is truthful. I accept all information given will be kept confidential, and
will not be released without my authority. I realise that I may be given vaccinations and understand what they are for, and side effects that
may be expected from them. I consent to having these vaccinations.
March 2019