Childhood Fluenz (Nasal Spray)

Section

Not ‘at-risk’ children should be age 2 or 3 years on 31/08/2024 (Date of birth between 01/09/2020 to 31/08/2022)

Is the patient aged 2-17 years inclusive? *
Is the patient immunocompromised due to:
Is the patient receiving salicylate therapy? (aspirin based therapy)
Is the patient allergic to eggs?
Does the patient have severe asthma?
Is the patient going to be having direct contact with any severely immunocompromised individuals in the next 2 weeks?
Does the patient have a very blocked or very runny nose?
Is the patient in an ‘at-risk’ group and under the age of 9 years? (i.e. they are having the vaccine for medical reasons not just age)
Is there any chance of pregnancy?

Consent

Is a parent accompanying the child to the appointment? *
*

Please specify below the name of the adult accompanying the child to the appointment:

I confirm the responses on this form are correct: