Screening questionnaire for intranasal influenza vaccination
For adult patients as well as parents of children to be vaccinated:
The following questions will help us
determine if there is any reason we should not give you or your child intranasal influenza vaccine (FluMist®)
today. If you answer “yes” to any question, it does not necessarily mean you (or your child) should not be
vaccinated. It just means additional questions must be asked. If a question is not clear,
please ask your healthcare provider to explain it.
1. Is the person to be vaccinated sick today?
2. Does the person to be vaccinated have an allergy to eggs or to a component of
3. Has the person to be vaccinated ever had a serious reaction to intranasal
influenza vaccine (FluMist®) in the past?
4. Is the person to be vaccinated younger than age 2 years or older than age 49 years?
5. Does the person to be vaccinated have a long-term health problem with
heart disease, lung disease, asthma, kidney disease, metabolic disease
(e.g., diabetes), anemia, or other blood disorders?
6. If the person to be vaccinated is a child age 2 through 4 years, in the past 12 months,
has a healthcare provider ever told you that he or she had wheezing or asthma?
7. Does the person to be vaccinated have a weakened immune system because of
HIV/AIDS or another disease that affects the immune system, long-term treatment
with drugs such as steroids, or cancer treatment with x-rays or drugs?
8. Is the person to be vaccinated receiving aspirin therapy or aspirin-containing therapy?
9. Is the person to be vaccinated pregnant or could she become pregnant within
10. Has the person to be vaccinated ever had Guillain-Barré syndrome?
11. Does the person to be vaccinated live with or expect to have close contact with
a person whose immune system is severely compromised and who must be in
a protective environment (such as in a hospital room with reverse air flow)?
12. Has the person to be vaccinated received any other vaccinations in the past 4 weeks?
Form completed by: ____________________________________________ Date: ______________ Form reviewed by: _____________________________________________ Date: ______________________
Technical content reviewed by the Centers for Disease Control and Prevention, September 2008.
www.immunize.org/catg.d/p4067.pdf • Item #P4067 (9/08)
Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Information for Health Professionals about the Screening Questionnaire for
Intranasal Influenza Vaccination
Are you interested in knowing why we included a certain question on the Screening Questionnaire? If so, read the information below. If you want to find out even more, consult the sources listed at the bottom of this page.
1. Is the person to be vaccinated sick today?
LAIV. Instead, they should be given TIV.
There is no evidence that acute illness reduces vaccine efficacy or
8. Is the person to be vaccinated receiving aspirin therapy
increases vaccine adverse events. Persons with an acute febrile ill-
or aspirin-containing therapy?
ness usually should not be vaccinated until their symptoms have im-
Because of the theoretical risk of Reye’s syndrome, children and
proved. Minor illnesses with or without fever do not contraindicate
teens on aspirin therapy should not be given LAIV. Instead they
use of influenza vaccine. Do not withhold vaccination if a person is
should be vaccinated with the injectable influenza vaccine.
9. Is the person to be vaccinated pregnant or could she be-
2. Does the person to be vaccinated have an allergy
come pregnant within the next month?
to eggs or to a component of the influenza vaccine?
Pregnant women or women planning to become pregnant within a
History of anaphylactic reaction—such as hives, wheezing, or diffi-
month should not be given LAIV. All pregnant women should, how-
culty breathing, or circulatory collapse or shock (not fainting)—after
ever, be vaccinated with the injectable influenza vaccine.
eating eggs or receiving any component of the intranasal live attenu-ated influenza vaccine (LAIV, tradename FluMist®) is usually a con-
10. Has the person to be vaccinated ever had Guillain-
traindication for further doses. Check the package insert for a list of
the vaccine components (i.e., excipients and culture media) used in
It is prudent to avoid vaccinating persons who are not at high risk for
the production of the vaccine, or go to www.cdc.gov/vaccines/pubs/
severe influenza complications but who are known to have devel-
oped Guillain-Barre syndrome (GBS) within 6 weeks after receiving a previous influenza vaccination. As an alternative, physicians might
3. Has the person to be vaccinated ever had a serious re-
consider using influenza antiviral chemoprophylaxis for these persons.
action to intranasal influenza vaccine in the past?
Although data are limited, the established benefits of influenza vac-
Patients reporting a serious reaction to a previous dose of LAIV
cination for the majority of persons who have a history of GBS, and
should be asked to describe their symptoms. Immediate—presum-
who are at high risk for severe complications from influenza, justify
ably allergic—reactions are usually a contraindication to further vacci-
11. Does the person to be vaccinated live with or expect
4. Is the person to be vaccinated younger than age 2 years
to have close contact with a person whose immune system
or older than age 49 years?
is severely compromised and who must be in a protective
LAIV is not licensed for use in persons younger than age 2 years or
environment (such as in a hospital room with reverse air
5. Does the person to be vaccinated have a long-term
Injectable influenza vaccine is preferred for persons who have close
health problem with heart disease, lung disease, asthma,
contact with severely immunosuppressed persons during periods in
kidney disease, metabolic disease (e.g., diabetes), anemia,
which the immunosuppressed person requires care in a protective
or other blood disorders?
Persons with any of these health conditions should not be given the
12. Has the person to be vaccinated received any other
LAIV. Instead, they should be vaccinated with the injectable influenza
vaccinations in the past 4 weeks?
Persons who were given an injectable live virus vaccine (e.g., MMR,
6. If the person to be vaccinated is a child age 2 through
MMRV, varicella, yellow fever) in the past 4 weeks should wait 28
4 years, in the past 12 months, has a healthcare provider
days before receiving LAIV. There is no reason to defer giving LAIV if
ever told you that he or she had wheezing or asthma?
they were vaccinated with an inactivated vaccine or if they have re-
LAIV is not recommended for children at this age with possible reac-
cently received blood or other antibody-containing blood products
tive airways disease (e.g., history of asthma or recurrent wheezing or
whose parent or guardian answers yes to this question). Instead, they should be given TIV.
7. Does the person to be vaccinated have a weakened im-
Sources:1. CDC. Epidemiology & Prevention of Vaccine-Preventable Diseases,
mune system because of HIV/AIDS or another disease that
et al., editors,
affects the immune system, long-term treatment
2. CDC. “General Recommendations on Immunization: Recommendations of the
with drugs such as steroids, or cancer treatment with x-
Advisory Committee on Immunization Practices (ACIP)” at www.cdc.gov/
rays or drugs?
3. CDC. “Prevention and Control of Influenza—Recommendations of ACIP” at
Persons with weakened immune systems should not be given the
Immunization Action Coalition • Item #P4067 • p. 2
Dear Patient: Thank you for choosing Asthma & Allergy Care of Delaware. Enclosed is a questionnaire for you to complete and return before seeing your doctor. Your appointment is confirmed as follows: __________________________________________________________________________________ Please complete the four pages of medical history and one page of insurance information before
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