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220 South Cliff Ave Ste. 120 Harrisburg SD 57032 Medical Group Harrisburg 20152016 Flu Vaccine Questionnaire Name: First Name MI Date of Birth: Last Name Address: City Home Telephone #: Female State
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How to fill out the 2015-2016 flu vaccine questionnaire:

01
Read the instructions: Start by carefully reading the instructions provided with the questionnaire. Make sure you understand the purpose and the questions that need to be answered.
02
Personal Information: Begin by filling out your personal information section. Include details such as your full name, date of birth, address, and contact information. This information is necessary for proper identification and record-keeping.
03
Medical History: Provide accurate information regarding your medical history. This includes any pre-existing conditions or allergies. It is important to disclose this information as it will aid healthcare professionals in determining your eligibility for the flu vaccine.
04
Vaccination History: Indicate your vaccination history, specifically whether or not you have received the flu vaccine in previous years. This information helps healthcare professionals track your immunization status and determine if you require additional doses.
05
Consent and Signature: After completing the questionnaire, carefully review your answers to ensure they are accurate. If you agree with the terms and conditions stated in the consent section, sign and date the form as required.

Who needs the 2015-2016 flu vaccine questionnaire?

01
Employees: Many workplaces require employees to complete the flu vaccine questionnaire to ensure a healthy workforce and prevent the spread of influenza within the organization.
02
Healthcare Professionals: Health practitioners need to fill out the questionnaire to ensure they are protected against the flu and minimize the risk of transmitting it to vulnerable patients.
03
Students: Schools and universities may request students to complete the flu vaccine questionnaire to ensure a safe and healthy learning environment.
04
Individuals with Certain Health Conditions: Those with chronic illnesses or compromised immune systems may be required to complete the questionnaire to assess their eligibility for the flu vaccine and any additional precautions.
It is important to consult with your healthcare provider or the specific organization requesting the flu vaccine questionnaire to determine if you are required to complete it.
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The flu vaccine questionnaire is a form used to gather information about an individual's flu vaccination status.
Employers are typically required to have their employees complete a flu vaccine questionnaire.
The flu vaccine questionnaire can be filled out by providing information about the individual's flu vaccination status and any related health information.
The purpose of the flu vaccine questionnaire is to ensure that individuals are properly vaccinated against the flu to protect themselves and others.
The flu vaccine questionnaire typically asks for information about the individual's vaccination status, any allergies or medical conditions, and contact information.
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