Influenza/Pneumococcal Immunization Record

1 Site/Clinic Location: Influenza / pneumococcal Immunization Record Last Name First Name Initial Gender Provincial health Care Number/ULI Age Date of Birth (yyyy-Mon-dd). Alberta Address Phone (Home). City Province Postal Code Phone (Other). Out of Province Address (if applicable) Province Status: New to Alberta Visitor Influenza Vaccine Informed Consent Vaccine (Manufacturer): Priority List by Reason Code: Fluzone (SF) mL IM Lot # _____. 03 health care worker FluLaval (GSK) mL IM Lot # _____. Other _____ Lot # _____. 46 Pregnant women 02 65 years of age and older Site: Arm Left Right 45 6 months up to and including 23 months Leg Left Right 60 24 months up to and including 59 months 63 5 years up to and including 8 years of age For children requiring a 2nd dose: 64 9 years up to and including 64 years of age Next dose due on or after _____.

2 Dose: Annual 1 of 2 2 of 2. pneumococcal Polysaccharide Vaccine Not Eligible Refused Referred to Public health for Conjugate Vaccine (Manufacturer): Informed Consent Pneumovax 23 (MF) mL IM. Priority List by Reason Code: 50 Routine recommended Immunization Lot # _____. 55 Medically at risk Site: Arm Left Right 57 High risk setting Dose: 1 Re- Immunization Date Vaccine(s) given (yyyy-Mon-dd) Immunizer's First Initial/Surname/Designation Signature health information is collected in accordance with Section 20 of the health Information Act (HIA) for the purpose of providing health services, determining eligibility for health services, or to carry out any other purpose authorized by the HIA.

3 If you have any questions about this collection, please ask the health care provider offering the Immunization or contact your local public health office. 09826(Rev2018-06). Immunizer's full name (Please Print) _____. Care After Immunization y Influenza y pneumococcal Polysaccharide Side Effects Many people have no reaction to these vaccines. If reactions happen, they are usually mild and go away in a few days. They may include: redness, swelling, and discomfort where fever or chills the needle was given poor appetite, nausea, vomiting, feeling tired or irritable stomach pain, or diarrhea headache or body aches Unusual reactions can happen.

4 Call health Link at 811 to report any unusual reactions. For more information about each vaccine, read the vaccine information sheets on or talk to your healthcare provider. How to Help Yourself Feel Better You can help yourself feel better by: placing a cool, wet cloth on the area where the needle was given moving the limb where the needle was given (to help the vaccine absorb). wearing fewer layers of clothing and drinking extra fluids if you have fever. For more information on fever, go to If you need fever or pain medicine: Check with your pharmacist or doctor. Do not give ASA (Aspirin ) to anyone younger than 19 years old, because it can cause serious health problems.

5 Before taking any medicine, read the package instructions to make sure you know about any warnings/precautions. Follow the dosage instructions on the bottle carefully. Some people with health problems ( , weak immune system) must call their doctor whenever they get a fever. If you have been told to do this, call your doctor even if you think the fever was due to Immunization . For More Information Call health Link at 811 Go to Go to Go to Alberta health Services (AHS) and Covenant Healthcare Workers report your influenza Immunization using the self-reporting form found on Insite (AHS) or CompassionNET (Covenant health ).

6 Your influenza Immunization status is used to appropriately plan, manage and allocate resources to protect patients, family and healthcare workers during the influenza season. This material is for information purposes only. It should not be used in place of medical advice, instruction or treatment. If you have specific questions, please consult your doctor or appropriate health care professional.