INITIAL: ______. DOB:______ SEX: ___ Email: ... strains circulating in the community. ⢠Protection from the vaccine is
INFLUENZA IMMUNIZATION CONSENT FORM 2017-2018 PLEASE PRINT:
LAST NAME: ___________________________________________ FIRST NAME: _________________________ INITIAL: ______ DOB:____________ SEX: ___ Email:_________________________
ADDRESS: ___________________________________________ CITY: _____________________ POSTAL CODE ____________ M:_______________ H: _______________ W: _______________
The Facts: Influenza, commonly known as “the flu”, infects 10 to 20% of Canadians every year. The flu vaccine is free for all those over 6 months of age who live, work or attend school in Ontario.
Side Effects: Serious side effects from the vaccine are very rare. • You cannot get the flu from the vaccine, as there is no live virus in the vaccine. At the time of year that the vaccine is given, many cold viruses are making people sick. Infection with these viruses may be mistaken for a reaction to the flu vaccine. • Some people have a sore arm for 1-3 days after getting the shot. A few people will have symptoms such as low fever, headache and muscle aches. These symptoms tend to be mild and end within one to two days. Rest, plenty of fluids and acetaminophen (e.g. TylenolTM) will help ease these symptoms. • Rarely- a few cases per year- an “oculo-respiratory syndrome’ (ORS) may occur. ORS is defined as red eyes, and/or respiratory symptoms (cough, wheeze, chest tightness, difficulty breathing, difficulty swallowing, hoarseness or sore throat), and/or facial swelling that is seen within 24 hours of vaccination. Generally, the symptoms are usually mild and do not need treatment. If you have had ORS symptoms after receiving the flu vaccine in the past, see your doctor before getting your next flu vaccine. • In 1976, the swine flu vaccine was associated with a severe paralytic illness called Guillain-Barré Syndrome (GBS). Flu vaccines since then have not been clearly linked to GBS. However, if there is a risk of GBS from the current flu vaccines, it is estimated to be, at most, one (1) case per million persons vaccinated - much less than the risk of severe influenza and/or its complications, which can be prevented by the flu shot. • It is important that you report any unusual or severe side-effects or any of the ORS symptoms to your family doctor. Who Should Not Get the Flu Vaccine? • Infants under 6 months of age; • Anyone with an allergy to one components of the vaccine • PLEASE ANSWER THE ALLERGY QUESTIONS • Anyone who has had a serious allergic reaction to a previous dose of the flu vaccine; • Anyone who is ill and has a fever should not receive the vaccine until he or she is feeling better.
The Virus: The flu is a serious respiratory disease caused by a virus. It spreads easily through coughing and sneezing. It can also spread through direct contact with surfaces contaminated by the flu virus. While some symptoms may be cold-like, the flu can be far more serious, causing fever, chills, cough, sore throat, headache and body aches. Although the fever may go away on the second or third day of illness, it may take up to six weeks to feel better. Complications, such as pneumonia, are more common in young children, the elderly and those who have chronic medical conditions. The Vaccine: The Fluviral vaccine contains part of the virus itself, but the virus used is dead and cannot give you the flu. Each year the flu vaccine is changed to protect against the strains that are expected to circulate. The 2017-2018 seasonal influenza vaccines can protect against the equivalent strains of: • A/Michigan/45/2015 (H1N1) pdm09-like virus, • A/Hong Kong/4801/2014 (H3N2)-like virus, • B/Brisbane/60/2008-like virus The vaccine is 50-60% effective in preventing flu infection in the overall population. Its effectiveness varies from year to year depending on a number of factors, including how well the vaccine “matches” the actual strains circulating in the community. • Protection from the vaccine is achieved two weeks after the injection and may last six months or longer. • Children less than 9 years old need 2 seasonal vaccine shots, given at least 4 weeks apart, if they haven’t had a seasonal flu shot before. • For those who receive the vaccine and still get the flu, it is usually milder than it would have been without the shot. The flu vaccine is considered safe during pregnancy and breastfeeding.
PLEASE ANSWER ALL THE QUESTIONS BELOW
Have you had a flu shot before? ALLERGIES: Have you ever had a serious reaction to , or a hypersensitivity to any of the following: 1. a previous dose of influenza vaccine? If yes, please describe 2. eggs (hives, breathing difficulties, swelling of the mouth &throat, anaphylaxis) 3. Are you allergic to sodium deoxycholate, ethanol, formaldehyde, sucrose, a-tocopheryl hydrogen succinate, polysorbate 80, or thimerosal (circle) Do you have a history of: Guillain-Barré Syndrome (GBS) or Oculo-Respiratory Syndrome (ORS) (circle) Do you have an active neurological condition? Are you immunocompromised? circle Do you currently have an acute illness and fever?
NO
YES
NO NO
YES YES
NO
YES
NO
YES
NO
YES
NO
YES
PLEASE READ THE INFORMATION ON THIS CONSENT FORM. I have read the information on the flu vaccine. I have had the chance to ask questions which were answered to my satisfaction. I understand the benefits and risks associated with this vaccine. I give consent to Algonquin College Health Services to administer the flu vaccine. I agree to wait in the waiting room for 15 minutes after being vaccinated. Signature: X _________________________________________________________ 2017 Influenza Consent Form
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