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Updated: April 20, 2009

HPV (Human Papilloma Virus) Vaccine Patient Information

Gardasil (Human Papilloma Virus) vaccine prevents the spread of the most common types of STD (Sexually Transmitted Diseases) and certain types of Cervical Cancer caused by the Human Papilloma Virus. The FDA approved recommended indications are: prevention of genital warts, cervical cancer, cervical adenocarcinoma, cervical vulvar and vaginal intraepithelial neoplasias.

Most human papillomavirus (HPV) infections occur without incident or treatment, but some may persist for years and eventually produce cellular abnormalities leading to illnesses. Approximately 100 HPV types cause warts and more than 30 HPV types have been linked to cervical cancer. The most common viruses are HPV 16 and 18, which cause more than 70% of cervical cancers. HPV types 6 and 11 are considered low-risk carcinogenic types, but they are responsible for 90% of genital warts. ACIP (Advisory Committee on Immunization Practices) clinical study findings show that the HPV vaccine was 100% effective in preventing cervical, vulva, and vaginal cancer; and 95% effective in preventing genital warts. The vaccine does not appear to be effective in women already exposed to HPV except for the virus types contained in the vaccine that they are not infected with.

In the United States, approximately 10,000 women will be diagnosed with cervical cancer each year, and an estimated 3,700 women will die from the disease. Cervical Cancer is the 2nd leading cause of death among women in the world.

The CDC (Centers for Disease Control) recommendations for this vaccine are only for girls and young women between the ages of 13 to 26 years of age for the prevention of sexually transmitted diseases. The vaccine should be administered before onset of sexual activity (before women are exposed to the viruses). It also recommends that adolescent girls and women in this age group who are sexually active should be vaccinated.

Abstinence or a mutually monogamous sexual relationship is the only effective method to prevent STDs completely. In all other cases, use a latex condom.

Get the 'What you need to know about the Gardasil (Human Papilloma Virus) vaccine The HPV vaccine is not a replacement for routine cervical cancer screening or an annual gynecologic examination. It must be remembered that other types of HPV cause cancer; therefore, annual PAP SMEARS must be continued.

HPV vaccine is a “three-dose” series vaccine administered with 0.5 ml IM (intramuscularly) in the upper arm at 0, 2, and 6 months (or initial shot now, then in 2 months, and final third shot at 6 months).

HPV Vaccine is manufactured by Merck & Company, Inc. under the Trade Name of *Gardasil and is a noninfectious inactivated quadrivalent HPV (types 6, 11, 16, 18) recombinant vaccine that contains highly purified virus-like particles.





GARDASIL or HPV VACCINATION Q & A Form
Printable PDF Version ->
ALVARADO MEDICAL PLAZA PHARMACY
5555 Reservoir Dr., Suite 114, San Diego, CA 92120
Ph. 619.287.5035 * Fax 619.287.5098
SCREENING QUESTIONNAIRE FOR GARDASIL or HPV VACCINATION
Patient Name: ________________________
Assessment Date: ____/____/20____
Weight _____(lbs) _____(kgs)
Date of Birth: ____/____/_____
PATIENTS: The following questions will help us determine if the Gardasil or HPV vaccine is appropriate to administer to you today. If a question is not clear, please ask the Pharmacist to further explain
YES
NO
Don't
Know
1. Are you a girl or young woman between the ages of 13-26? (HPV vaccine is only FDA for this age group)
2. If you are under the age of 18, we require written consent from your parent or legal guardan on this form.
3. Are you ill (sick) tody? (Do you have a temperature of 101.3F degrees or higher?)
4. Have you had an allergic reaction to any previous vaccinations?
5. Are you allergic to yeast?
6. Are you currently being treated for any immune disorders (HIV/AIDS, cancers, bone marrow, lymphatic diseases or taking any medications such as Prednisone or any other corticosteroids? (Taking medications or having a disease that can reduce the body's immune response can result in a decrease in the effectiveness of the vaccine.)
7. Are you aware that HPV Vaccine is administered in 3 doses or a "three-series" shot? (First shot now, second in 2 months and the final shot at 6 months.)
8. Are you pregnant or is there a chance you could become pregnant? (Pregnant women should not get the vaccine.)
I have read, or have had explained to me, the question listed above. I have had the opportunity to ask questions that were answered to my satisfaction. I have read and been provided the current Gardasil or HPV VIS (Vaccination Information Statement) published by the CDC. I understand the benefits and risks of the vaccination cited and request this vaccination to be administered intramuscularly to myself or the person listed above (for whom I am authorized to make this request). For first time vaccinations, I understand that it is essential that I remain on location for approximately 15 (fifteen) minutes following administration.

Form consent/completed by: ____________________________ Date: ____/____/20___
---OFFICE USE ONLY---
Vaccination Administered by: ___________________________
Did the patient experience any reaction? YES NO