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)
度
℃
( )
( )
Date of Birth
Birth weight
(↑予防接種番号シールをはってください)
Body temperature before exam.
なかった
Please answer following questions about the growth history of the child.
Answers
あなたのお子さんの発育歴についてお尋ねします。
質問 事項
Questionnaire for Vaccination
いいえ
No
Yes
氏名
保
護
者
の
方
は
太
線
枠
内
を
記
入
し
て
く
だ
さ
い
Parent /guardian, ; Please fill those cells surrounded by thick line.
No. of vaccination
出生体重
予防接種番号
Vaccination No.
( 月 日: ) ( 月 日: ) ( 月 日: )
( 月 日: ) ( 月 日: ) ( 月 日: )
(Date :Name )
あった
Yes
ある
Yes
出生後に異常がありましたか。
Yes
はい
Date : (
接種回数 ←初回1回目は 1、初回2回目は 2, 初回3回目は 3, 追加接種は 4を記入してください。
← Mark "1" for the first, "2" for the 2nd, "3" for the 3rd of the first series and "4" for additional vaccination.
千葉市 区
電話
(Date :Name )
住所
フリガナ
)
性別
あった なかった
はい
Did the child have any congenital abnormalities, heart, kidney, liver, cranial nerve, immune deficiency, or
any other diseases since birth, on which you have consulted with any doctors on those diseases including
ー
Year
分娩時に異常がありましたか
Did the child have any abnormalities at delivery?
g
※
こ
の
用
紙
は
機
械
で
読
み
取
り
ま
す
の
で
黒
ボ
ル
ペ
ン
で
丁
寧
に
書
い
て
く
だ
さ
い
Tel.
実 施 日 ※医療機関記載欄
Date to be administered ※to be filled in by medical institution
医師記入欄
(↑ Place the vaccination number sticker here)
診察前の体温 分
保護者氏名
Name of Parent or Guardian
datemonth
Degree C
西暦
Yes
はい
(Date :Name )
Name
生年月日
Address
ー
2 0
year
Did the child have any abnormalities after birth?
乳幼児健診で異常があると言われたことがありますか。
W ere any abnormalities found in infant health checks?
(
1か月以内に病気にかかりましたか。
As this sheet is read by a machine, please write carefully with a black ball point pen,
病名
Did the child become ill in the past month?
病名 ( 月 日: )
1か月以内に、家族や遊び仲間にはしか、風しん、みずぼうそう、おたふくかぜなどの 病気の方が
いまし たか。 病名( 月 日: )
Have any family members or friends of the child had measles, rubella, chicken pox or mumps in the past
month ? Describe name of disease and date ( Date : )
1か月以内に予防接種を受けましたか。 (日付:種類)
Did the child have any vaccinations in the past month ? If so, dates and names of vaccinations.
Yes No
Yes
はい
生まれてから今までに先天性異常、心臓、腎臓、肝臓、脳神経、免疫不全症、その他の病気にかか
り、医師の診察(投薬など)を受けていますか。
はい
Yes
Does the child hve any poor conditions today ?
今日体に具合の悪いところがありますか。
具体的な症状を書いてください。 ( )
If so, describe symptoms. (
date
今日受ける予防接種について、千葉市から配られている説明書を読みましたか。
Have you read the document from Chiba City explaining about today's vaccination?
いいえ はい
No Yes
(Name in Katakana)
子の満年齢
Age of the child
か月
years Months
回答 欄
年 月 日
month
Name of diseases
Had the child a convulsion or fit in the past? If so, around what age ? ( years months)
Disease name
(Date :Name )
(Date :Name )
その病菌主治医には、今日の予防接種を受けてよいと言われましたか。
ひきつけ(けいれん)をおこしたことがありますか。( 歳 か月頃) )
Did the doctors in charge of the above diseases agree to he child receiving today's vaccination ?
(Date :Name )
No
ない
No
いいえ
No
いいえ
No
いいえ
No
いいえ
No
はい
Yes
いいえ
No
いいえ
No
はい
Yes
Yes
いいえ
No
はい
If you answered " yes" to the above, did the child have a temperature at the same time ?
そのとき熱がでましたか。
01
Questionnaire for Pneumococcal vaccine for an infant Chiba City
2 小肺
歳
小児用肺炎球菌 予防接種予診票 千葉市