Health Question Health Question
1) Are you being treated for an infection today?
6) Do you have any chronic cardiac, pulmonary or diabetic
7) Do you have an active neurological disorder?
3) Have you received an influenza (flu) vaccine before?
8) For Agriflu, are you allergic to:
Note: Children under nine years of age who are getting
the seasonal flu shot for the first time require two doses of
4) Have you ever had a serious reaction to
9) For Vaxigrip, are you allergic to:
10) Are you taking any Coumadin or other blood thinners?
I acknowledge that I have read The Regional Municipality of York’s Influenza (Flu) Fact Sheet, or it has been read to me. I understand the benefits and possible side effects of the influenza (flu) vaccine and that certain persons listed in the Influenza (Flu) Fact Sheet should not get the influenza (flu) vaccine. I consent to the influenza vaccine being given to me or my child. In addition, I am aware that personal health information collected on this form may be shared with another doctor or nurse if that is required for my care. Should you not want your information released to another doctor or nurse, please check below or advise the Health Unit in writing. If signing for someone other than yourself, you must be the appropriate substitute decision maker. Please indicate your relationship to that other person: _____________________ Please check if you do not want your information released to another doctor or nurse. Signature: ____________________________________ Print Name: _________________________________ Date of signature: _______________________________
Vaccine: Agriflu Vaxigrip Dosage: FOR CLINIC NOTES: The information provided or attached to this form is being collected for use by the local Medical Officer of Health to maintain an immunization record on the
above named individual and to take appropriate action to prevent certain vaccine preventable diseases in the health unit. This information may be disclosed to
the Ministry of Health and Long-Term Care or other health units for the purpose of the prevention of vaccine preventable diseases. For further details about this collection, you can contact the Manager of Community Clinics of the Infectious Di
seases Control Division by calling (905) 830-4444, ext. 3578.
For more information, please call Health Connection at 1-800-361-5653, TTY 1-866-252-9933 or visit www.york.ca/flu Influenza Fact Sheet What is influenza?
redness, or swelling where the shot was given that will go away in a few days.
Influenza, also known as “the flu”, is a serious, highly contagious respiratory infection that is much worse
If an allergic reaction is going to occur, it will usually
happen within a few minutes after receiving the shot. This is why it is important to stay at the flu clinic for
Seasonal flu is caused by regular flu viruses. If you
15 minutes after your shot, so the nurses can watch
get the seasonal flu, you may experience a cough,
fever, chills, sore throat, headache, muscle aches and fatigue.
Most people who get the flu are ill for a few days, but
Note: If you are ill with a fever, wait until you have
some can become very sick. Babies, very young
children, pregnant women and people with serious
health problems can become seriously ill.
See your physician to get the flu shot if you have:
• had a serious allergic reaction to a previous dose
of influenza vaccine or any component of the
Flu viruses spread quickly and easily
• developed Oculo-Respiratory Syndrome (ORS)
• touching unwashed hands or contaminated
• ever experienced Guillain-Barré Syndrome (GBS)
surfaces and objects and then touching your
• A person can spread the flu from the day before
becoming sick until several days afterwards
Prevent the spread of the flu virus:
Wash your hands with soap and water thoroughly
About the seasonal flu vaccine
• Each year there is a new vaccine to protect
Use an alcohol-based sanitizer. Keep an alcohol
against the flu strains that are expected in the
hand sanitizer handy at work, home and in your
coming flu season. Even if the strains have not
car. It needs to be 60% alcohol to be effective
changed, getting the flu shot every year
Cough and sneeze into your upper sleeve or a
tissue, not your hand. Dispose of tissues
It takes about two weeks for protection to develop
after receiving your flu shot, and the protection
Stay home when you are sick and limit contact
• The vaccine is effective in about 70 to 90 percent
• Children under nine years of age who are getting
Keep common surfaces and items clean and
the seasonal flu shot for the first time require two
doses of the vaccine, at least four weeks apart.
• Experts have concluded that people who are
allergic to eggs may receive the seasonal influenza vaccine.
Serious side effects are very rare, but a few people may have mild side effects, such as soreness,
For more information, please call Health Connection at 1-800-361-5653, TTY 1-866-252-9933 or visit www.york.ca/flu
PO Box 1860 • Catoosa, OK • 74015 • 918.266.5764Personal Profile (please fill out every space clearly and legibly) What Global Ventures Trip(s) have you been on? (Country/Year)Filled with the Holy Spirit? According to Acts 2:4 Have you ever received treatment or counseling for alcohol or substance abuse?Are you currently doing, or been involved with any of the following during the pas
President Bob Domine called the meeting to order and read the Agenda. Recognition Awards were present by Bob Domine and VP Volunteers Linda Domine to volunteers who made extra efforts in their volunteering to GAOC for the past year. The following volunteers were given certificates of appreciate plus one year of free GAOC membership and an extra volunteer coupon good for one free meet. Shawn Calla