New Location - learn more

Randolph County Health Department
1319 E Hwy 24, Suite A, Moberly, MO 65270

660-263-6643
660-263-0333

Flu Assessment Screening and Consent Form

moving to new location
Flu Assessment Screening and Consent Form

General Information

Gender *
Ethnicity
Race *
(Number, Street Name, Apt/Suite)

Insurance Information

Are you insured under your parent/guardian’s insurance plan?
Gender

Please answer the following questions:

Are you sick today (cold, fever, cough, nausea/vomiting)?
Do you have a serious allergy to eggs, chicken, or feathers?
Do you currently have Guillain-Barre Syndrome (severe muscle weakness or paralysis)?
Ever had a serious reaction to any previous flu vaccine or any vaccine?
Have you received vaccines or injections in the last 4 weeks?
Are you taking antibiotics, prednisone, cortisone, anti-cancer or other medications that might prevent you from getting the vaccine?
Have you had the influenza (flu) vaccine before?
Are you pregnant or do you plan to become pregnant in the next 4 weeks?
Have you checked with your doctor?
Do you faint with injections?
Do you have asthma or a chronic health condition?

Please check the box below to provide acknowledgement/consent:

Consent *

© Randolph County Health Department