Form Mg-5667 - Adult Immunization Record Form
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1
2Adult Immunization Consent Form
Name: _________________________________________ Home address:________________________________________
Telephone number: (Home) ________________________ (Work)_______________________________________
Date of Birth: ____/____/____
_________/______________/__________
Year/month/day
9 Digit Manitoba Health Number (PHIN#)
Health History completed by:
Client
Health Care Provider
Legal Decision-Maker
1. Are you well today?
Yes
No (If no, describe): ______________________________
Date:
g
Date:___________
2. Do you have any allergies?
Yes
No (If yes, describe): _______________________________
3. Do you have any health conditions that require regular visits to a doctor?
Yes
No (If yes, describe):
_______________________________________________________________________________________________________
4. Do you have any conditions that can suppress your immune system (i.e., HIV infection, problems with spleen, organ
transplant, etc)?
Yes
No (If yes, describe): ____________________________________________________________
Note: Tell the nurse or doctor if you are taking treatment, i.e., steroids, chemotherapy, radiotherapy, etc.
5. Have you experienced a reaction to a vaccine in the past?
Yes
No (If yes, describe): ___________________________
6. Are you pregnant or considering becoming pregnant within one month?
Yes
No
N/A
*Legal decision-maker’s signature:
_________________________________
Date:
_______________________________________
Notice: Information about the immunizations you or your child(ren) receive may be recorded in the provincial immunization
registry. This registry allows your health care providers to find out what immunizations you or your child(ren) have had or need
to have. Information collected in the provincial immunization registry may be used to produce immunization records, or notify you
or your doctor if a particular immunization has been missed. Manitoba Health, Seniors and Active Living may use the information
to monitor how well different vaccines work in preventing disease. The Personal Health Information Act protects your information.
You can have your personal health information hidden from view from health care providers. For more information, please contact
your local public health office to speak with a public health nurse
Section to be completed by the immunization provider:
Verbal Consent:
The legal decision-maker has been made aware of the benefits and the risks of the vaccine(s) offered to the above person and consents for the
identified person to be immunized on the following date: ___________________________________________________________________
The legal decision-maker has agreed to complete the Adult Immunization Consent Form provided to him/her and agreed to forward the completed
form to this immunizaton provider. Provider signature: _______________________________________ Date: ________________________
The following vaccine(s) will be given: Indicate with a check ( √ )
Td – tetanus, diphtheria
IPV – inactivated polio
MMR – measles, mumps, rubella
Rabies (series)
Hepatitis A (series)
HRIG – Human Rabies Immune Globulin
Hepatitis B (series)
HBIG – Hepatitis B Immune Globulin
Hepatitis A & B (series)
Meningococcal (conjugate or polysaccharide)
Influenza
Varicella
Pneumococcal (conjugate or polysaccharide)
Typhoid (oral or injectable)
Tdap – tetanus, diphtheria, pertussis
Cholera
Other: ______________________________________
Other:
______________________________________
Immunization Interventions: Initial and date completed intervention(s)
Provided and reviewed fact sheet(s)
Date: _______________
Explained to report vaccine side effects Date: _____________
Answered questions and concerns
Date: _____________
Other: ___________________________ Date: _____________
Immunization record given to client
Date: _____________
Health history completed
Date: _____________
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Parent category: Medical