Recommendations for Influenza Vaccination

Age of person (enter a decimal fraction if less than 12 months old)

Person's gender

Current date (as MM/DD/YYYY)

Is the person a resident of a chronic medical care facility?

Does the person have a chronic pulmonary disorders or risk factors for aspiration?

Does the person have a chronic cardiovascular disorder?

Does the person have a chronic metabolic disease, including diabetes mellitus?

Is the person immunosuppressed?

Is the patient HIV-positive?

Does the person have a sickle cell disease or other hemoglobinopathy?

Does the person have chronic renal dysfunction?

Does the person have chronic liver disease?

Is the person taking aspirin on a long-term basis?

Is the person pregnant?

Is the woman in the second or third trimester of the pregnancy?

Is the person a physician, nurse or other health care provider?

Is the person an employee of a nursing home or chronic care facility?

Does the person provide home care to or live with a person at high risk for influenza-related complications?

Does the person live with someone at high risk for influenza-related complications?

Is the person a caregiver of a child less than 5 years old?

Is the person an overseas traveler?

Is the person going to the tropics now?

Is the person going to the Southern Hemisphere from April through September?

Does the person provide an essential community service (police, fire fighter, etc.)?

Does the person reside in an institutional setting (dormitory, etc.)?

Does the person wish to reduce the likelihood of becoming ill with influenza?

Has the patient received the influenza vaccine before?

How many months ago did the person last receive the vaccine? (if more than 12 months, enter 12)

Was the last dose of flu vaccine the first the child had ever received?

Has the person had an anaphylactic reaction to eggs?

Has the person had an anaphylactic reaction to other components in the flu vaccine?

Has the person had an anaphylactic reaction or other serious reaction to the flu vaccine before?

Does the patient have a history of Guillain Barre syndrome within 6 weeks of receiving influenza vaccine?

Does the person have an acute febrile illness?