INFLUENZA VACCINE CONSENT FORM
Last Name: First Name: Male Female
Address: City: Postal Code:
Telephone: Physician:
Date of Birth: Year Month Day Age:
Health Card Number: Version:
Please answer the following questions:
- Are you 65 years of age or older? Yes No
- If yes, have you had a slip, trip or fall within the past year? Yes No (if yes, complete back of page)
- Are you a child 6 months – 4 years of age? Yes No
- Do you live/work/volunteer in a nursing/retirement home? Yes No
- Are you a health care worker or emergency care worker? Yes No
- Are you a child care worker? Yes No
- Are you a household contact/caregiver to an infant less than 6 months old, or a
household contact/caregiver to anyone who has a compromised immune system? Yes No
I have read the information about the influenza vaccine and have had the chance to ask questions, which were answered to my satisfaction. I consent for myself, or the above-named, to receive the influenza vaccine. I understand that I am expected to wait 15 minutes at the clinic after the vaccine is given.
Signature:(in ink) Date:
I consent for Public Health to inform my physician that I have received the influenza vaccine. Yes No
For Nurse’s Use Only:
Age group and dosage for seasonal influenza vaccine
6 months to less than 9 years 0.5 ml IM, 2nd dose may be needed
9 years and older; adults0.5 ml IM, 1 dose only
Vaccine / Dosage / Site / Lot Number / Date / Time / Administered By(write full signature, with designation)
Agriflu®
Comments:______
______
This information is being collected pursuant to the Health Protection and Promotion Act, R.S.O.1990, c.H.7 and will be retained, used, disclosed and disposed of in accordance with the Municipal Freedom ofInformation and Protection of Privacy Act, R.S.O. 1990, c.M.56, the Personal Health InformationProtection Act, 2004, S.O.c.3 and all applicable federal and provincial legislation and regulations governing the collection, retention, use, disclosure and disposal of information. Any questions regarding this collection may be directed to the Director of Finance and Administration at 101 17tht Street East, Owen Sound, Ontario, N4K 0A5, (519)376-9420.
FALL PREVENTION SCREENING
Please complete the optional questionnaire below and talk to your health care provider about resources offered to decrease falls, and injuries from a fall, in our community.
Client First and Last Name: / Date of Birth:DD/MM/YYYY / Sex: □ M □F
Have you fallen?
If yes, how many times? / □Yes □ No
______
Have you experienced a near fall?
(E.g. slip, trip, stumble, or bumped against a wall?) / □Yes □ No
Have you previously reported any falls to a health professional?
If so, how many falls? / □Yes □ No
______
Have you ever sought medical attention for a fall? / □Yes □ No
Have you limited any of your activities or decreased how much you leave
your home due to a fall, near fall, or fear of falling? / □Yes □ No
NURSE TO COMPLETE BOTTOM PORTION OF FORM
If 3 out of the 5 falls screening questions are answered yes, offer a referral to their family health team/health care provider.
Name of Primary Health Care Provider or Family Health Team:
Consent received from client to: / Declined referral today:□ send a referral to Health Care Provider or Family Health Team / □ Client will follow-up with his/her health care provider
□ provide falls prevention resources only (resources
provided to client)
Comments:
Influenza vaccine consent form adapted with permission from the Grey Bruce Health Unit