)
( )
Date of Birth
Birth weight
(↑防接種番号シルをはっください
Body temperature before exam.
Please answer following questions about the growth history of the child.
Answers
Questionnaire for Vaccination
No
Yes
Parent /guardian, ; Please fill those cells surrounded by thick line.
No. of vaccination
Vaccination No.
            
            
Date :Name    
Yes
Yes
Yes
Date :
1 12 2,  3 3,   4
Mark "1" for the first, "2" for the 2nd, "3" for the 3rd of the first series and "4" for additional vaccination.
  
Date :Name    )
)
sex
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
Year
Did the child have any abnormalities at delivery
g
Tel.
Date to be administered to be filled in by medical institution
(↑ Place the vaccination number sticker here
西           
Name of Parent or Guardian
datemonth
Degree C
西
Yes
Date :Name    
Name
Address  
2 0    
year
Did the child have any abnormalities after birth?
W ere any abnormalities found in infant health checks?
(
As this sheet is read by a machine, please write carefully with a black ball point pen,
Did the child become ill in the past month?
              
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 ? If so, dates and names of vaccinations.
Yes No
Yes
Yes
Does the child hve any poor conditions today ?
   ( )
 If so, describe symptoms. (
date
Have you read the document from Chiba City explaining about today's vaccination?
No Yes
(Name in Katakana)
Age of the child
years Months
Doctor's
comment
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    
)
Did the doctors in charge of the above diseases agree to he child receiving today's vaccination ?
Date :Name    )
 
No
No
No
No
 
No
No
Yes
No
No
Yes
Yes
No
If you answered " yes" to the above, did the child have a temperature at the same time ?
01
Questionnaire for Pneumococcal vaccine for an infantChiba City
2
 
  
date
1. Name of the inoculated person: ( ) Date of Birth:
2. Address :
3. Date of inoculation :
Lot No.
Lot No.Manufacturer
Propriety of inoculation
0.5ml
Has the child ever had a rash or hives on his skin, or become ill with medications or food ?
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
Yes
No
No
Yes
Have any close relatives of the child been diagnosed as congenital immune deficiency?
Yes
6まし
No
No
Yes
注)グロは、剤の、Aなど症の的や感染療目で注こと、こを3月以けた麻しの予
の効ないあり
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
Year
Manufacturer
Lot No.
Expiration date
西
A.D.
 (
たう、接
ださ
を理 とに
YES
NO
1
Month
Name of Institution
Code
Doctor's column
Code
No
No
Has the child received a transfusion of blood or an Injection of gamma globulin in the past 6 months?
( )
Do you have any questions about today's vaccination?
If yes, please describe. ( )
Yes
I made explanation on the effectiveness of the vaccination, side reactions, and the inoculation health hazard relief system.
Signatureor seal of the Doctor in charge
This column is to be filled in by parent/guardian or by the representative. (In case of a representative, a power of attorney is required separately.)
The child has 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 inoculation 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
Hypodermic injection
(
Date of Birth
Record of Neumo coccal vaccine for an infant (for records of Medical institution)
              
 
 
Signature or seal of parent/guardian or the representative.
Doctor's Name. In case of "no", name of the Doctor
who made the judgement