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H1N1 Nasal Spray Vaccine Qualification Questionnaire

 

To qualify for the vaccine you must meet criteria established by the CDC that puts you at high risk for complications to the flu AND meet qualifications for the nasal spray vaccine as that is the ONLY vaccine available. Please respond to the following statements.

 

1. I am pregnant.                                                            Yes                      No        

 

2. I have a serious underlying health condition (ie, asthma, chronic obstructive pulmonary disease (COPD), diabetes, chronic cardiovascular disease and those with compromised immune systems)                                                                        

                                                                                              Yes                      No

 

If you answered YES to any of the above statements nasal spray vaccine is CONTRAINDICATED; please return the questionnaire and obtain the injectible H1N1 vaccine when it is available. If you answered NO to both, please continue.

 

3. I am between the ages of 2 years and 24 years.                                    

Agree                   Disagree

 

4. I am a health care worker AND less than 50 years old.                      

Agree                   Disagree

 

5. I live with or care for a child under 6 months of age AND are less than 50 years old.                  

Agree                   Disagree

 

6. I have NOT taken antiviral drugs (Tamiflu, Relenza in the past 2 weeks.                                                                        

Agree                  Disagree

 

7. I do NOT have close contact with anyone with a weakened immune system such as a person who has had a bone marrow transplant.                                                       

Agree                  Disagree

 

8. I do NOT have any problems with  your immune system, such as cancer, treatment for cancer, HIV, leukemia, bone marrow or other transplant.                           

Agree                  Disagree

 

9. I do NOT have a muscle or nerve disorder than can lead to breathing or swallowing problems, such as MS, seizures, or cerebral palsy.                                   

Agree                  Disagree

 

10. I am NOT a child or young adult receiving aspirin or aspirin containing therapy.                                                   

Agree                  Disagree

 

11. I have NOT had the nasal seasonal influenza, MMR, or Varicella vaccine in the past 28 days.                               

Agree                  Disagree

 

12. I do NOT have allergies to egg or any components of the nasal vaccine (MSG, gelatin, arginine,  or gentamycin)                                        

Agree                  Disagree

 

                                                                                                                 

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