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| 1. What is your age? |
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| 2. Do you plan to move out of the Nashville area in the next year? |
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| 3. Have you added any new medications or changed dosages recently? |
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| If yes, provide the medication name and when it was changed or added. |
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| 4. Have you had a “flu shot” or vaccination in the last six months? |
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| If yes, provide the type of injection and date/s of injection. |
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| 5. Have you ever had a bad reaction to any flu shot? |
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| If yes, explain the reaction and type of injection. |
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| 6. Do you have a problem with drug or alcohol abuse? |
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| 7. Have you been in any other research study in the last 3 months? |
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| If yes, provide start/stop dates. |
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| 8. Do you have problems with your immune system? |
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| 9. Do you have asthma or COPD? |
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| If yes, please list medications you take or any recent hospitalizations. |
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| 10. Do you have any other serious medical problems like uncontrolled hypertension, heart failure, respiratory problems, seizure disorders, or a history of cancer? |
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| If yes, provide details of medical condition. |
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| 11.Please list all medications you take, whether on a daily basis or as needed. |
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| First Name: |
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| MIddle Initial: |
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| Last Name: |
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| Email Address: |
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| Phone Number: |
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| Address: |
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| Date Of Birth: |
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| Which vaccine study are you interested in participating in? |
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| Where did you hear about this study? |
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