Hepatitis B (B 型肝炎) vaccine: Vaccination Register and Screening Questionnaire
北区Address

M・F

Patient's name

Parent/guardian name回目

Date of birth:Age:years

対象年齢months

Phone

Vaccination history

First vaccination received (yearsmonths )Please fill in the question items in the bold box below and circle one of the answer columns.

Body temperature before interview

Questionnaire for Vaccination℃Answer1.

Have you read the document (sent to you previously from your city) about the vaccination that will be administered today?

NoYes

2.

Was your child born to a mother who tested positive for hepatitis B virus?

Yes*

No

3.

Please answer about your child’s development history.
Did the child have abnormal findings at delivery?

Yes

No

Did the child have any abnormal findings after birth?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Has the doctor treating disease told you that the child could have the vaccination today?

Yes

No

9.

Are you currently taking any special medication, such as steroids or immunosuppressants

Yes

No

10.

Has the child had a seizure （spasm or fit）in the past?

Yes

No

Did the child have a fever at that time?

Yes

No

11.

Has the child ever had a rash or hives or become ill because of the medications or food?

Yes

No

12.

Does the child have a family member or relative with a congenital immunodeficiency?

Yes

No

13.

Has the child ever become ill after the vaccination?

Yes

No

14.

Has any family member or relative of the child had a serious reaction to a vaccination in the past?

Yes

No

15.

Do you have any question about the vaccination?

Yes

No

Birth weight () gram

Have you ever been told any abnormal findings at an infant health check?
4.

Is the child sick today?
If so, describe the specific symptoms. ()5.

Did the child have a disease within the last one month? Name of disease ()6.

Has any family member or friend of the child had disease such as measles, rubella, chickenpox or mumps within one month?
Name of disease: (7.

)

Has the child been vaccinated in the past month?
Name of vaccination (8.

Date of vaccination;/)

Does the child have a congenital anomaly, heart, kidney, liver, central nerve disease, immune deficiency, or any other diseases for which you
have consulted a doctor?

医師
記入欄

Doctor'scomment

Name of disease ()If Yes:age () years old.

２＊に該当する場合、母子感染予防に係る保険診療のため、定期予防接種の対象外であることを説明しました。
保護者に対して、予防接種の効果、副反応及び予防接種健康被害救済制度について、説明をしました。
以上の問診及び診察の結果、今日の予防接種は（実施できる・見合わせたほうがよい）と判断します。

医師署名又は記名押印

使用ワクチン

Entry column for parent/guardian:
I have been interviewed and explained by the doctor.

I have understood

実施場所・接種医師名(注)有効期限が切れていないか要確認

the benefit, objectives, and risk of serious side effects, and also the Relief
System for Health Damage by Vaccination. Now, I confirm my intent on□ビームゲン 0.25mL

taking vaccination as follows.

□ビームゲン 0.5mL〒114-0003□ヘプタバックス-II

東京都北区豊島 5-5-5-107(Agree・Not agree)

This screening questionnaire is used to improve the safety of vaccination.
I understand the above and agree that this questionnaire can be submitted□ヘプタバックス(シリンジ 0.25)
Lot No.としま町クリニック
電話 03-3927-3778

to the City.

(注)有効期限が切れていないかを要確認

Signature of Parent/Guardian or Companion

接種部位
左 ・ 右

実施機関名・住所・電話番号

上 腕 ・ 大 腿

接種医師名

接種（予診）年月日

年月日