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General Information - Influenza Vaccination
The Disease: Influenza (flu) is caused by viruses. The fever, chills, headache, dry cough and
muscle aches of flu may last from several days to more than a week, but complete recovery is
usual. Certain groups of people, however, are much more likely to suffer major complications if
they get the flu. People over age 65, residents of nursing homes and other chronic care facilities,
people with diabetes, heart disease, lung disease, chronic severe anemia including sickle cell
disease, cancer, chronic immunosuppressive disorders and pregnant women who will be in the
second or third trimester during the influenza season are among those at higher risk for
complications. Health care personnel who have contact with high risk patients should be
vaccinated to protect themselves and their patients.

The Immunization: One injection will protect most people from influenza caused by the different
types of virus contained in the vaccine. The vaccine contains the types of influenza virus
predicted to be present during the coming influenza season. Yearly immunization is necessary
because new strains of virus develop quite often and immunity wanes. Although definitive
studies have not been conducted, the Center for Disease Control and Prevention considers the
influenza vaccine safe in any stage of pregnancy.
The composition of the vaccine is changed yearly to make certain the annual vaccine
represents the strains that are most likely to be encountered during the upcoming season.
Immunization against influenza viruses focuses on types A and B because type A influenza is
most commonly responsible for epidemics and type B influenza also causes significant illness.
• Optimal time to receive vaccine is mid-October through mid-November; however, the vaccine is administered anytime during influenza season. • Immunity lasts for one influenza season only. • Possible side effects are slight fever, fatigue, muscle ache, and tenderness and redness at the injection site. Current vaccines are more highly purified than older preparations and less likely to be associated with fevers and local reactions. • This vaccine should not be administered to individuals with a history of hypersensitivity (allergy) to chicken egg, Guillain-Barre syndrome, or acute febrile illnesses. The vaccine is derived from virus grown in embryonated hens eggs, and is contraindicated in individuals who are allergic to eggs. • The virus in the vaccine has been killed and is not infectious. The influenza vaccine does • Women who will be in the second or third trimester of pregnancy during the influenza season should be vaccinated, preferably after the first trimester. • This vaccine may be administered simultaneously with pneumococcal, MMR, and polio • The 2011/12 Flu vaccines are designed to protect against the three influenza viruses that experts predict will be the most common during the upcoming season. Each season, this includes an influenza B virus, an influenza A (H1N1) virus and an influenza A (H3N2) virus. (These are the three virus subtypes that are circulating most commonly among people today.). It will not prevent illnesses caused by any other viruses.
Influenza Immunization Informed Consent
Name:_______________________________________ S.S.# :_______________________________________ Potential contraindications
Are you currently ill and have a fever? Have you ever had a bad reaction to the flu vaccine? Have you ever had Guillain-Barre Syndrome (GBS)? Are you allergic to the preservative thimerosal?
Side Effects: Side effects are infrequent. The few people that do notice side effects will
usually experience very mild symptoms for 1-2 days, including a slight fever, tiredness,
muscle ache and tenderness and redness at the injection site. A severe allergic reaction
is possible, although rare, so we ask you to remain 10 minutes after your immunization for
observation. If you are taking Warfarin (Coumadin), Theophylline, or Dilantin the vaccine
may affect your blood level.
Gullain-Barre Syndrome is a rare illness first associated with influenza immunization during the use of the "Swine Flu" vaccine in 1976. Approximately one person per 100,000 who received the Swine Flu vaccine later developed Gullain-Barre Syndrome. Gullain-Barre Syndrome has not been associated with the recent flu vaccines, but individuals with a past history of GBS should discuss immunization with their health care provider.
Consent:
I have received the information sheet about Influenza and the Influenza Vaccine. I have
read the above statement about the Influenza Vaccine and have had the opportunity to
ask questions. I understand the possible benefits and risks of the vaccination. I request
the Influenza Vaccine to be given at this time.

Office use only
* Any Yes response to questions above must have vaccination recommendation by provider (MD)
___ Patient is an appropriate candidate for Administered by: _______________________

Source: http://www.mdurgentcare.com/influenza_form.pdf