Yellow fever Questionnaire and Acceptance Record

 

This questionnaire is needed before our clinic administers the Yellow fever immunization to travelers. It is important to give this vaccine for the right reasons. Travelers may need it either because it is required by the countries they travel to or suggested because of the current risk of yellow fever where they will be.

 

 

Yes

No

Are you Allergic to any part of any vaccine?

 

 

Do you have an egg or chicken allergy?

 

 

Did you ever have any reaction to any shot or vaccine?

 

 

Have you ever fainted?

 

 

 

 

 

Do you have any Medical Condition?

 

 

For Women- Are you pregnant or likely to become pregnant?

 

 

 

 

 

Do you have any condition that could affect immunity?

 

 

Examples: HIV, AIDS, Leukemia, Lymphoma, Cancer, Thymus disease,

 

 

Myasthenia gravis, or any other immune disorders

 

 

 

 

 

Are you taking methotrexate or other immune modifying drugs?

 

 

Are you taking a daily prednisone pill?

 

 

 

 

 

Have you received any treatment- Radiation therapy, Chemotherapy that may affect your immunity

 

 

 

 

 

Have you read all the information provided on Yellow fever

 

 

Do you have any questions?

 

 

 

 

 

Reason why you are receiving Yellow fever:

My trip requires yellow fever because:

 

I don't need yellow fever for this trip but plan to be travelling to a yellow fever area in the future ‹

 

I have read this and understand the risks and benefits of receiving Yellow fever.

I have had a chance to ask questions which were answered to my satisfaction.

I consent to this vaccine being given to me.

I agree to wait in the waiting room 15 minutes after so I can be assessed for any possible reaction.

I will seek medical attention should I expierence any unusual especially allergic symptoms.

 

Name: Date:

Signature

(Parent or guardian if under 18yrs)

Clinic use only: Immunizer:

Vaccine lot Number:

Site of injection: R L

(Additional comments on back)

 

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