Microsoft word - sns-t29-00 region 3 naph form -flu.doc

Region 3 Strategic National Stockpile
PATIENT MEDICAL HISTORY and CONSENT FORM
Please PRINT the Following Information

Last Name:_______________________________________ First Name: ___________________________________________
Middle Name: ________________________ Date of Birth: ____/____/____ Age: _______ Gender: M ____ F ____

Mother’s Maiden Name: ______________________ Weight (if under 100 lbs): __________lbs.
Street Address:_______________________________ City: ________________________ State: _______ Zip: ____________
County: ___________________ E-mail (optional): ________________________________________
Home Phone: (____)______________________ Alternate Phone: (___)_________________________

Do you have flu-like symptoms today (fever, aches, chills, cough)? YES
NO (circle one)
Do you have a known latex allergy?
NO (circle one)
Are you allergic to eggs?
NO (circle one)

FEMALES ONLY:
Are you currently pregnant or think you might be pregnant?
NO (circle one)
Are you currently breastfeeding?
NO (circle one)
List All Known Allergies:
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Do YOU (or the minor you are filling this out for) have any of the following medical conditions?
(Circle the correct answer for each question):

Do you have or had a seizure disorder (such as epilepsy, etc.)? Do you take vitamins or supplements (Calcium, Iron, Zinc, Magnesium, Multivitamin, etc.)? Do you use antacids (Tums, Maalox, Mylanta, Rolaids, Pepto-Bismol, etc.)? Do you have an immunosuppressed medical condition (i.e. HIV/AIDS, Cancer, Lupus, Organ Transplant) Taking a Medication Containing Steroids and/or for Cancer Treatment Do you have a history of Guillian Barre Syndrome Long-term Health Problem Such As: Heart Disease, Kidney Disease, Liver Disease, Diabetes, Lung Disease, Asthma, Anemia, Other (please indicate)___________________________
List Any Medications You Are Currently Taking:
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Additional Medical Information/Concerns:
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ PARTICIPANT CONSENT OR REFUSAL TO RECEIVE VACCINATION OR MEDICATION
I HAVE: 1) been informed of reasons why I am being vaccinated/receiving medication; 2) received the vaccine/medication fact
sheet indicating the risks and benefits of the vaccine/medication, its side effects, and where I will be able to receive additional
information if side effects were to develop; 3) received information about the infectious agent; 4) had an opportunity to have my
questions answered.
CONSENT: Participant Signature/Parent or Guardian: ____________________________________ Date: ___________________

REFUSAL: Participant Signature/Parent or Guardian: ____________________________________ Date: ___________________
THIS SIDE FOR STAFF USE ONLY
To Be Filled Out For Prophylaxis Medication
Name of Medication:

TAMIFLU 75mg 1X Day
Other Medication: _________________________________________
TAMIFLU __________
Dose: ______________________________________________

Quantity Dispensed:
10 Day Supply
50 Day Supply
60 Day Supply Other____________

Manufacturer: __________________ Lot #: ______________________ Exp Date: _____________________
Did the patient receive a medication Fact sheet? (Circle one) YES

Notes (if applicable): ____________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Staff Signature: ________________________________________________ Date: __________________________
To Be Filled Out For Vaccination
Name of Vaccination (Circle One): Influenza
OTHER: ____________________________

Vaccination Site (Circle One): LEFT ARM RIGHT ARM
OTHER: ____________________________

Manufacturer: ______________________________________
Dose Amount: ______________________

Vaccine Lot #: _____________ Diluent Lot #: _____________ Batch #: _____________ Exp Date: ___________
Notes (if applicable): ____________________________________________________________________________
______________________________________________________________________________________________ ______________________________________________________________________________________________
ASK PATIENT: Have you ever received the influenza vaccine? YES NO

Did the patient receive the Vaccination Fact Sheet? (Circle one) YES NO
Staff Signature: ________________________________________________ Date: __________________________
If Patient Went to Infirmary/Received Counseling
Counseling/Treatment Given By:
Name _____________________________________________ Title: _____________________________________
What was the outcome? Clinician Notes: ___________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

Source: http://www.dhd2.org/files/Medical%20Screening%20Form%20Flu.pdf