1.
Are you currently pregnant?
yes
no
2.
Have you ever experienced a severe reaction to a flu vaccine?
yes
no
3.
Have you ever experienced a severe reaction to eggs?
yes
no
4.
Do any of the following describe you: chronic heart or lung disease, diabetes, kidney failure, immunosuppression, asthma, child on long-term aspirin therapy, child with history of wheezing?
yes
no
5.
Are you suffering from moderate to severe illness today?
yes
no
6.
Select your age:
< 6 months
6-11 months
1 year
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65 +
7.
Select your state:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY