Pre-Vaccination Screening Questionnaire for COVID-19 Vaccine (Booster shot)*Please fill in or check the ☑ boxes inside the bold frame
Address on
theresident
cardPrefecture（space for your vaccination voucher / sticker)

Address

Furigana

Phone
No.

Name
Date ofbirth

注意：
本予診票を用いて請求を行うことはできません。
日本語の予診票に転記の上、請求を行ってください。

CityYear ／Month ／

Day

（（）
－Body temperature
before examination□male・□female

years old）

＿ ＿ ．＿

Response field

Question
Have you ever received the COVID-19 vaccine before?
(If yes, date of 1st dose: YYYY/ MM/ DD, date of 2nd dose:(VaccineDD)）□YES□NOIs the city, town, or village where you currently reside the same as the city, town, or village statedon the coupon?

□YES□

NO

Have you read the "Instructions for the COVID-19 vaccine" and do you understand the effects andadverse side effects?
Are you currently suffering from any kind of illness and receiving treatment or medication?
Name of disease: □heart disease □kidney disease □liver disease □blood disease□YES□NO□YES□NO)□YES□NO)□YES□NO

Have you ever had a convulsion (seizure)?

□YES

□

NO

Have you ever experienced severe allergic symptoms (such as anaphylaxis) from medications orfoods? Medication or food that caused the problem ()

□YES

□

NO

Have you ever been sick after receiving a vaccine?
Type of vaccine () Condition (□YES□NO

Is there any possibility that you are currently pregnant (for example, your period is later thanexpected)? Or are you breastfeeding?

□YES□

NO

Have you had any vaccines within the last two weeks?
Type of vaccine ()Date of vaccine (□YES□NO□YES□NO□disease that makes it difficult to stop bleeding□capillary leak syndrome

YYYY/MM/□immune deficiency□other () □ other ()Name of disease (Are there any parts of your body that are not feeling well today?

Condition ())

Do you have any questions about the vaccine today?
Fordoctors
use only

In light of the results of the questions above and examination, today's vaccine is(□possible, □not possible).
I have explained the effects of the vaccine, side effects, and the Relief System for Injuryto Health with Vaccination to the patient.

For Medicalinstitution
use only◯outside the doctor’s hour （time in:

Field filled inby doctor)

Nature of treatment:□blood-thinning medicine (Have you had a fever or gotten sick in the last month?

DegreesCelsius） ◯non-consultation day

Signature and seal of doctor◯child (under 6) ◯spare① ◯spare②*Please check by blacking in the appropriate circle

COVID-19 Vaccination Request Form

After receiving a medical examination and explanation from a doctor and understanding the effects and side effects of the vaccine,do you wish to receive this vaccine? （□ I wish to be vaccinated/ □ I do not wish to be vaccinated ）Signature ofvaccinated personor their guardian

The purpose of this preliminary medical examination form is toensure the safety of the vaccine.

Date:

I understand this and consent to this Pre-Vaccination Screening
Questionnaire being submitted to the municipal government, theAll-Japan Federation ofNational
Health Insurance
Organizations, and the National Health Insurance Organization.

(*If the person to be vaccinated is unable to sign the form by himself/herself, a representative mustsign the form, and the representative's name and relationship to the person to be vaccinated must
be indicated.)(*In the case of a person under 16 years of age, the form must be signed by the guardian; in thecase of an adult ward, the form must be signed by the person himself/herself or the adult guardian.)

Field filled in by doctor

Name of vaccine and lot number

Inoculation
amountVaccination location, name of doctor, and date of vaccination*Please fill in the medical institution code and vaccination date so that they fit within this field.

Vaccination location

Seal position*Paste seal upright to align with the edges of the frame.
(Note: Make sure that the expiration date has notexpired.)

YYYY/ MM/ DD

Medical institution code

＿ ＿ ＿ ＿ ＿ ＿ ＿ ＿ ＿ ＿＿ . ＿ ＿ml

Name of doctor

Date of vaccination*Example: April 1, 2021 →2021/04/01

YYYY / MM / DD