Are you evaluating a patient for intranasal vaccination against influenza using the live virus preparation?

Gender of the patient

Age of the patient


Is the patient pregnant?

Is the patient receiving chronic aspirin therapy?

Is the patient receiving immunosuppressive therapy?

Is the patient immunocompromised by disease, including HIV disease?

Does the patient have?

• a chronic cardiovascular, pulmonary, or renal disease?

• a history of hypersensitivity to egg proteins?

• a history of Guillain-Barre syndrome?

• a history of recent respiratory illness (within past 72 hours)?

• a history of recent anti-influenza drug therapy (within 48 hours of stopping)?

• household contact with a severely immunocompromised patient ?

• occupational contact with severely immunocompromised patients?


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