Microsoft word - 2013 flu_mist consent.doc

504-456-8515
FLU-MIST IMMUNIZATION CONSENT
2013/2014
Flu MIST
Influenza (flu) is a respiratory disease caused by influenza virus infection. The types, or strains, of influenza virus that cause illness
may change from year to year, or even within the same year. People who get flu may have fever, chills, headache, dry cough, and
muscle aches, and may be sick for several days to a week or more. Most people recover completely. However, for some people, flu
may be especially severe, and pneumonia or other complications, including death, may occur.
Vaccine
Flu Mist vaccine contains live attenuated influenza virus of the four types selected by the U.S. Public Health Service and the Center
for Biologics Evaluation & Research of the U.S. Food and Drug Administration. The types of virus included are those that have most
recently been causing influenza. The vaccine will not give you flu because it is an attenuated virus vaccine. As with any vaccine, flu
vaccine may not protect 100% of all susceptible individuals.
Risks and Possible Side Effects
Influenza vaccine generally causes only mild side effects that occur at low frequency. Most commonly, the reactions may be a runny
nose, or possibly fever, chills, headache, or muscle aches. These side effects usually last 24 to 48 hours. Most people who receive the
vaccine either have no reaction or only mild reactions. There is a possibility, as with any vaccine or drug, that an allergic or other
serious reaction, or even death, could occur. Also, medical events completely unrelated to the vaccine may occur coincidentally
following vaccination. I have read the CDC Vaccine Information Statement.
Unlike the 1976 swine influenza vaccine, flu vaccines used since then have not been clearly connected with an increased frequency of
Guillain-Barré syndrome, which is associated with paralysis.
The following questions will help us determine if the Flu Mist vaccine may be given today. If a question is not clear, please ask
the nurse to explain it:
If “yes” is applicable, the intranasal flu vaccine mayor may not be advised.
Are you allergic to eggs or egg products or chicken proteins?
Are you under age 2 or over age 50?
Do you have a history of Asthma or reactive airway disease or are you wheezing today?
Are you a child or adolescent receiving aspirin therapy or aspirin-containing therapy?
Do you have contact with severely immunocompromised individuals in hospital isolation?
Are you moderately or severely ill? i.e. do you have a fever? (Fever over 101ºF) wait 72 hours For Women: Are you pregnant or breast feeding? If yes, please let the nurse know
Are you on or have you been on antiviral therapy such as Tamiflu or Relenza? Must wait 48 hours after final
dose of antiviral and should not receive antivirals for 2 weeks following Flu Mist unless medically indicated.
Have you received a live vaccine such as MMR, Varicella, or Yellow Fever in the past 4 weeks? Must wait 4
If you experience any significant reactions, see your physician.
I have read the above information about Influenza and Influenza vaccine, and I have had a chance to ask questions. I
understand the benefits and risks of Influenza vaccination and request that the vaccine be given to me and or my minor child.

Name: _______________________________________________________ Date of Birth: ____________________ Age: __________ Street Address: _________________________________________ City: ___________________ State: ________ Zip: ____________ Signature: ______________________________________________________ Daytime Phone #:____________________
FOR CLINIC USE ONLY: Date of Vaccination: Manufacturer & Lot # Medimmune________________
Administered By: Clinic Site: Payment: _____________
Revised 7/31/2013 www.passporthealthlouisiana.com Offices conveniently located in Metairie, Baton Rouge, Covington and Lafayette 504-456-8515** 225-636-2601**985-590-4507

Source: http://www.stgeorgesepiscopal.com/files/2013FluMistConsent.pdf