Full Name *		Sex	Male Female Other
DOB *		Age *
Phone *		Email *
Address
GP Surgery		Consent to share info with GP if required	Yes No

Clinician has checked correct details*	Yes No
Consent to storage of health information	Yes No

*Good practice to check that contact details are correct and current.

Client is able to consent *	Yes No
Client is accompanied by someone able to consent on their behalf*	Yes No N/A

*(Mother, father or other adult with parental responsibility, legal guardian or person with lasting power of attorney).

Details of person consenting on behalf of another
Name		Relationship / legal status
Address

The client is happy to go ahead with the consultation and treatment. The clinician will explain the recommended treatment, including relevant benefits, potential side effects, and appropriate measures for managing any adverse reactions. *

Yes No

Use this information with the PGD to assess suitability for the vaccine. Note that some of this information will not necessarily exclude treatment, but will provide a better understanding of the patient. It may influence advice provided during the consultation.

Do you have any allergies? (Egg, latex or other)	Yes No
Have you ever had a severe allergic reaction, or a reaction to a vaccination in the past?	Yes No
Do you feel unwell or have a temperature today?	Yes No
Do you have kidney or liver problems?	Yes No
Are you pregnant or breast feeding?	Yes No
Do you have a low immune system or take medication that can affect your immune system? (e.g. steroids, treatment for cancer)	Yes No