AUCKLAND, HAMILTON, NEW PLYMOUTH, PALMERSTON NORTH, CHRISTCHURCH, NELSON

PATIENT ‘FLU’ VACCINATION FORM

Date:
Family Name: First Name:

Address: Date of Birth:

Male / Female

Are you a New Zealand Citizen  Resident  NHI Number:

Contact email address:

Contact Phone Number: (Home) (Work) (Mobile)

Occupation: Company Name:

General Practitioner (Name and Address)

Next of Kin: (Name and Contact Phone Number)

YOUR HEALTH
Do any of the following apply to you?(please tick)

Pregnant? Yes  No 
Age 65 years or older? Yes  No 
Diabetes? Yes  No 
Chronic respiratory disease (asthma only if taking regular preventative medicine) Yes  No 
Chronic renal disease Yes  No 
Cardiovascular disease Yes  No 
Current cancer Yes  No 
(excluding basal and squamous skin cancer if non invasive?)
Other conditions? (please specify) ____________________________________________________

Please answer the following, if you tick ‘YES’ to any of these, please make one of our vaccination team aware
Are you currently unwell with a high fever ? Yes  No 
Do you have a bleeding disorder? Yes  No 
Are you allergic to eggs, egg proteins, any poultry products e.g chicken feathers? Yes  No 
Have you ever suffered an allergic response to a vaccine in the past? Yes  No 
Do you, or have you ever had Gullian-Barre Syndrome? Yes  No 
List any known allergies: ____________________________________________________________

Please list any MEDICATIONS you are currently taking, Include those that affect the immune system, or that you have had within the last
2 months.

Informed consent: I acknowledge that the information given above is truthful. I accept all information given will be kept confidential, and
will not be released without my authority. I realise that I may be given vaccinations and understand what they are for, and side effects that
may be expected from them. I consent to having these vaccinations.

Please circle, then sign. SELF / PARENT / CAREGIVER(GUARDIAN) Signature: ...............................................................………..

March 2019