Vaccine QuestionnaireFirst Name *Last Name *Email *Does the person to be vaccinated have an allergy to an ingredient of the vaccine? *...select...YesNoHas the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? *...select...YesNoHas the person to be vaccinated ever had Guillain-Barré syndrome? *...select...YesNoIs the person to be vaccinated pregnant?...select...YesNoSignature *CleareSignatureField
