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H1N1 Pre-Registration

Step 1 of 3: Enter Your Information

Instructions:
Enter the information below for the person to be vaccinated. After the information is entered and the questions are answered, click the OK button to save and print your form. After you print the form in step 3, you will be able to enter another person to be vaccinated.

H1N1 Pre-Registration Form
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ex. 3305551234 Help

NOTE: Bold fields above are required.

Answer ALL of the following questions:

Is the person being vaccinated pregnant? Yes No
Does the person being vaccinated provide direct patient care? Yes No
Does the person being vaccinated care for children younger than 6 months old? Yes No
Does the person being vaccinated have a fever? Yes No
Has the person being vaccinated had a severe reaction to any medication or vaccines? Or, ever had an allergy to eggs, gentamicin, arginine, streptomycin, neomycin, polymixin B, thimerosal, gelatin, or latex? Yes No
Has the person being vaccinated ever had Guillain-Barre syndrome? Yes No
Has the person being vaccinated received any vaccine in the past 30 days? Yes No
Does the person being vaccinated have any of the following: asthma, diabetes, or disease of the lungs, heart, kidneys, liver, nerves, or blood? Yes No
Is the person being vaccinated a child that is on long-term aspirin or aspirin-containing therapy? Yes No
Does the person being vaccinated have a weakened immune system? Yes No
Does the person being vaccinated have close contact with a person who needs care in a protected environment (i.e. recent bone marrow transplant)? Yes No
If the person receiving the vaccination is 9 years of age or younger, is this their SECOND dose of the H1N1 vaccine?
If Yes, when was first dose? (MM/DD/YYYY)
Yes No
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