Munroe Regional Medical Center - New York City



| | |

|Assessed by: ,RN/LPN Date: |

|Pneumococcal Vaccine (Screen and administer year around) |Influenza Vaccine (Screen year around. Administer per vaccine availability. If |

|Vaccine indicated if any of the following apply: |vaccine unavailable, provide education re high-risk status and need to receive the|

|Patient is high-risk if either of the following: |following October.) |

|65 years of age or older. |Vaccine indicated (if any of the following apply): |

|Resident of nursing home or chronic care facility regardless of age |Patient is: |

|OR |50 years of age or older (higher-risk) |

|Patient is 18-64 and has any of the following high-risk conditions: |Resident of nursing home or chronic care facility regardless of age (high-risk) |

|Serious long-term health problem with chronic heart or lung-disease (not |OR |

|including asthma), diabetes mellitus, or kidney disease including nephrotic |Patient is 18-64 and has any of the following high-risk conditions: |

|syndrome |Serious long-term health problem with chronic heart or lung disease (including |

|Compromised immunity such as: Hodgkin’s disease, leukemia, lymphoma, multiple |asthma), diabetes mellitus, kidney disease, or anemia and other blood disorders. |

|myeloma, generalized malignancy, HIV/AIDS, organ or bone marrow transplant, |Compromised immunity such as: Hodgkin’s disease, leukemia, lymphoma, multiple |

|treatment with long-term corticosteroids, cancer drugs, or radiation therapy |myeloma, generalized malignancy, HIV/AIDS, organ or bone marrow transplant, |

|Alcoholism, cirrhosis, or chronic liver disease |treatment with long-term corticosteroids, cancer drugs, or radiation therapy |

|Sickle cell anemia or prior splenectomy |Women who will be pregnant during the influenza season. |

|Cerebrospinal fluid leaks |Conditions that can cause breathing problems. |

|OR |OR |

|Patient uncertain about prior vaccination status or history unreliable and meets |Patient uncertain about prior vaccination status or history unreliable and meets |

|any of the above criteria. |any of the above criteria. |

|Vaccine not indicated if none of the above. | |

|STOP ASSESSMENT! |Vaccine not indicated if none of the above. |

| |STOP ASSESSMENT! |

|Vaccination Status or Contraindications (Check all that apply) |

| Pneumococcal vaccine NOT INDICATED if any of the following: | Influenza vaccine NOT INDICATED if any of the following: |

|Previously immunized after age 65 (Date: __________) |Previously immunized this flu season (Date: _________) |

|Previously immunized before age 65,but ................
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