)
( )
122, 33 6 1
Mark "1" for the first time "2" for the 2nd time "3" for the 3rd time. Target people are from 6th grade of
elementary school to 1st grade of high school or equivalent..
Name
0
Please answer following questions about the growth history of the child.
Answers
Questionnaire for Vaccination
Did the child have any abnormalities at delivery or after birth ?
g
Parent /guardian, ; Please fill those cells surrounded by thick line.
No. of vaccination
Vaccination No.
( )
sex
No
Has the child had a serious reaction to a vaccine in the past?Name of Vaccine             
Have any close relatives of the child had a serious reaction to a vaccine ?
Yes No
Yes
Birth weight
Yes
Yes
Did the doctors in charge of the above diseases agree to the child receivig today's vaccination ? No
)
W ere any abnormalities found in infant health checks?
Does the child have any poor conditions today ?
   ( )
 If so, describe symptoms. (                              
 
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 including dosage?
  Address
Has the child ever had a rash or hives on his skin, or become ill with medications or food ?
Did the child become ill in the past month? (Disease name : Date : )
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 (
Did the child have any vaccinations in the past month ? Vaccine name and date ? ( )
Date to be administered to be filled in by medical institution
西              
 
(Name in Katakana)
Age of the child
years Months
Parent
or gurardian' name
Year
(↑防接種番シーをはってださい)
Body temperature before exam.
Degree C
西
  
2
Tel.
 
year month date
Have you read the document from Chiba City explaining about today's vaccination?
No Yes
(↑ Place the vaccination number sticker here
datemonth
Doctor's
comment
 
Date of Birth
Did the child have a temperature at the same time ?
Yes
Yes
Did the child have a convulsion or fit in the past? If so, around what age ? (
years
Yes
Disease names
No
No
 
No
Yes
No
 
No
Yes
months)
No
No
No
No
2
Questionnaire for HPV vaccineGardasil) Chiba City
2 HPV4
HPV( 
Yes No
No
Yes
Have any close relatives of the child been diagnosed as congenital immune deficiency?
Yes
Yes
Yes
As this sheet is read by a machine, please write carefully with a black ball point pen,
date
1
1. Name of the inoculated person: ( ) Date of Birth:
2. Address :
3. Name of medical Instituion
Lot No.
 
4. Date of inoculation :
Manufacturer
Date of Birth
 メーー名
ロッ
YES
NO
Propriety of inoculation
Parent/Guardian's column and confirmation of agreement (in case recipient is over 13years old and without any person to accompany)
I have read the explanation on HPV vaccination and, understanding the effects, purpose, potential serious side effects of the vaccination and inoculation
heath relief system. Based on the above, I (Agree or Disagree) to the implementation of the Vaccine.
( )
6ンマまし
Do you have any questions about today's vaccination?
If yes, please describe. ( )
Yes
西
A.D.
Code
No
No
 
Signature of parent/guardian or its representative or by the recipient herself if she is married.
Doctor's Name. In case of "no", name of the Doctor
who made the judgement
Code
Doctor's column
I made explanation on the effectiveness of the vaccination, side reactions, and the vaccination health hazard relief system.
Signature or seal of the Doctor in charge
注)ロブ血液種で炎な症のや重症のなどれるり、を3以内方はなど
の効いこます
0.5ml
HPV防接
(被種者用)
1回目・2回・3回目
Remark ; Granma Globulin is a blood product to be injected for prevention of infection diseases like Hepatitis A and for treatment of serious infection diseases. There are cases that vaccination of measles etc.,
may not e effective for those people who received Gamma Globulin injection in the past 3 to 6 months
(保
を受うえるこ
 )くだ
とに
HPV vaccination for record for recipient) [1st 2nd 3rd]
3.
医療関名
)
disagree, vaccination will not be made. Understanding that this questionnaire is to
I (Agree or Disagree ) to the vaccination.
secure the safety of vaccination, I agree that it will be submitted to Chiba City.
This column is to be filled in by parent/guardian or by the representative or recipient herself if she is married.(in case of a representative, a seperate
power of attorney is required.)
Recipient received medical examination and I received the explanation by the doctor. I further received explanation about the effects, purpose, potential
serious side effects of the vaccination and vaccination heath relief system. Based on the above, I (Agree or Disagree) to the implementation of the
Vaccine. ( Please circle either of Agree or Disagree in the parenthesis.) In case of disagree, vaccination will not be made. Understanding that this
questionnaire is to secure the safety of vaccination, I agree that it will be submitted to Chiba City.
Dosage
Intramuscular Injetion
(
Month
Name of Institution
Is there a possibility that you might be pregnant, for example, delayed menstruation, etc. ?
This vaccine is not recommendable to a pregnant, or to those who might be pregnant.
Yes
No
Has the child received a transfusion of blood or an Injection of gamma globulin in the past 6 months? Yes
( Please circle either of Agree or Disagree in the parenthesis.) In case of
被接者氏
生年
2 所      千市       区
4 種年
Year
Parent/guardian Signature
Address
Emergency contact
13
HPV
うえこと ・ )
かっどちらを○でください同意」はでき
ん。票は種の確保を目的とす。
とを理解の診票提出とにす。
Manufacturer
Lot No.
Expiration date