OCCUPATIONAL HEALTH SERVICE
Seasonal Influenza Immunisation Consent Form 2010
PRIVATE & CONFIDENTIAL
SECTION A
Office use only
Input date & intls
Personal Details
Surname:
Forename(s):
Date of Birth:
Telephone number:
Occupation:
Location:
Address:
Employer:
Please tick
 NHSG
 Aberdeen Council
 Aberdeenshire Council
 Moray Council
 B.T.S
 S.A.S
 Other
G.P.Med. Practice
Address:
Please answer the following question and mark either the ‘Yes’ or ‘No’ with an X, giving details where required
SECTION B
Medical Details
Yes
1.
Do you take tablets/medicine for any reason?
2.
Are you allergic to anything - food (e.g. eggs), drugs, animals
etc?
3.
Do you suffer from asthma or hay fever?
4.
Do you suffer from a chronic or recurring illness?
5.
Are you or do you think you may be pregnant?
6.
Are you breast feeding at present?
7.
8.
9.
No
Dates & Details
Have you had any severe reactions to previous vaccines e.g.
rash, tongue swelling, shortness of breath?
Have you had any other immunisations or vaccinations during
the last six weeks?
In the event you suffer an anaphylactic reaction following
immunisation you agree to the administration of adrenaline IM
as per NHS guidelines.
I have read the Influenza Information Leaflet and had the procedure and its implications explained to me.
The above information is correct and I consent to having Influenza Vaccine.
SIGNATURE:
DATE:
OHS Nurse / Advisor:
I have explained the procedure and administered the following vaccine:
Date
Vaccine
Dose
Route
Expiry
SIGNATURE:
PRINT NAME:
DATE:
Batch