ࡱ> GIFe bjbjJJ 4*(_b(_bn~ ZZ8$D_*f^^^^^)))))))$+{.*T"TT*ZZ^^9*TZ8^^)T)V'd(^3' )/*0_*'x3/j3/d(d(&3/(@L6;,g**0l_*TTTT3/ B : SEMC INFLUENZA VACCINE ADMINISTRATION RECORD 2020-2021 Information about the person to receive vaccine. Please Print Please Answer the Following Questions Are you allergic to eggs or egg products? Yes _____ No _____ Are you allergic to Thimerosal (a preservative)? Yes _____ No _____ 3. Have you ever had Guillain-Barre Syndrome? Yes _____ No _____ Have you been ill or had a fever within the last 48 hours? Yes _____ No _____ 5. Have you had the flu shot before? Yes _____ No _____ If yes, did you have any reaction to the flu vaccine? Yes _____ No _____ B. If yes, what were the symptoms? _____________________________________ C. Symptoms occurred how many years ago? _____________________________ 7. If female, are you pregnant? Yes _____ No _____ If you have had recent chemotherapy, radiation therapy, or steroids (except inhaled), these conditions may decrease the effectiveness of the vaccine. However, unless you physician has told you different, flu vaccination is still encouraged. I have read or have had explained to me the Vaccine Information Statement about influenza and influenza vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of influenza vaccine and ask that the vaccine be given to me. Sleepy Eye Medical Center will keep this record. Signature: _________________________________ Date: _____________ Administrative Use Only:Date Administered/VIS given: _____/_____/_____Date of VIS: ____/___/__Lot#: Mfg: CSL MED SKB NOV PMC PSC CPT code: 90662: Fluzone High Dose greater than 65 years (PMC) 90682: FluBlok 18years and older 90686: Fluarix-Quad 6 months and older (GSK) 90672: Flu Mist age 2-49 (MED) Other: Route:Site:Name and title of vaccine administrator:     File Name: 2020-2021 Influenza Vaccine Administration Record Reviewed: ln 8-1-2020 Last Name_________________________First Name ________________________ MI ________ Address ____________________________ City _________________ State ____ Zip _______ Date of Birth ___________ Age ______Nurse initials____ Family Physician: __________________ Allergies ___________________________________ Primary Clinic: ____________________ /02479:;GQz|   ' ( 1 3 4 G ^ ` m x y ǼtlthcCJaJhhh7CJaJhh_CJaJhhykCJaJhh/CJaJ hh)x56CJ\]aJhh)xCJaJh[:Jh_CJaJ h_CJ h)x5\h_jhh7UhuVCJaJh}nCJaJh(jh)xhh/&:z{|}~1  & F ^`gd1( LLZ^L`Zgd1( & F ^`gd1(gd)x$a$gdh7gd)x$a$gd)x$a$gd)xgd)x B D P Q Z ^ ! # * - @ A 4 ` } _ ` a øvrh)xhh)xCJh[:Jh)xCJaJh[:JhCJaJh[:Jh CJaJh[:Jh'u6CJaJh[:Jh)x6CJaJhhh7CJaJh[:Jhh76CJaJhcCJaJh%dCJaJhh)xCJaJhh/CJaJhh CJaJ% Z @ A 3 4 _ ` |wrgd)xgd)x`gd1(`gd1(gd1( $`a$gd1($a$gd1($^`a$gd1($LZ^L`Za$gd1($^`a$gd1($ & F ^a$gd1($ LZ^L`Za$gd1( 9dT$V&`#$/Ifgd80Mkd$$If:|))  t 6`V 064:` ap yt[:J$V&`#$/IfgdHgd)x -8GObcjmoy !FJhr߷}p`Wh8 H*OJQJh8 h8 CJH*OJQJaJh8 CJH*OJQJaJh./CJH*OJQJaJhYQSCJH*OJQJaJhYQSOJQJhdnOJQJhjOJQJh[:JOJQJhtJh[:JOJQJh[:JCJOJQJaJ htJh[:JCJOJQJ^JaJhtJh[:JCJOJQJaJ"htJh[:J5CJOJQJ\aJ9:@AH[KK5ux$V&`#$/If]ugdH$V&`#$/IfgdHkd$$If:0|)Sc  t 6`V064:` apyt[:JHScoJt X =d$V&`#$/Ifgd  X =d$IfgdH X =d$V&`#$/Ifgd8  X =d$V&`#$/IfgdHux$V&`#$/If]u^gdH   ^ijklOĵęhTh1(h&6nB*CJaJphhuVB*CJaJphh_h1(B*CJaJphhP;AjhP;AUh)xhtJh[:JCJOJQJaJh80MOJQJhtJh[:JOJQJh[:JH*OJQJ=---$V&`#$/IfgdHkd$$If:F |)4  t 6`V06    4:` apyt[:J=86666gd[:Jkd$$If:F |)4  t 6`V06    4:` apyt[:J  jklmuvgd[:Jgd_gdcgd)x21h:p1(/ =!"#$% $$If!vh#v):V :  t 6`V 06,5)4:` p yt[:J$$If!vh#vS#vc:V :  t 6`V06,5S5c4:` pyt[:J$$If!vh#v4#v#v:V :  t 6`V06,54554:` pyt[:J$$If!vh#v4#v#v:V :  t 6`V0654554:` pyt[:Js2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ )xNormalCJ_HaJmH sH tH J@J )x Heading 2$$@&a$56CJ\]D@D )x Heading 3$$@&a$ 5CJ\DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 44 )xHeader  !2>@2 )xTitle$a$5\>B@> )x Body Text$a$ 6CJ]2J@"2 )xSubtitle5\<P@2< )x Body Text 2$a$CJHBH @s Balloon TextCJOJQJ^JaJ4 @R4 /Footer  !N@bN t Comment Text dCJOJQJaJB/qB tComment Text CharOJQJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<v } } * mmmp   9H 8@(  V  # "? 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