Prevaccination Screening Questionnaire for COVID-19 vaccine*Please fill in or check the ᣌ boxes inside the bold frame
Address onPrefecture
theresident cardὀពᮏணデ⚊䜢⏝䛔䛶ㄳồ䜢⾜䛖䛣䛸䛿䛷䛝䜎䛫䜣䚹᪥ᮏㄒ䛾ணデ⚊䛻㌿グ䛾ୖ䚸ㄳồ䜢⾜䛳䛶䛟䛰䛥䛔䚹

CityAddress
Furigana

(Tel.
No.

Name
Date ofbirth)-ƑPDOHƑIHPDOH
YearMonthDay(years old)

Body temperature
before examination

Question

Degrees

Response field

Are you receiving the COVID-19 vaccine for the first time?
(If you have been vaccinated before, date of 1st time:MM/‫ ڧ‬yes‫ ڧ‬noIs the city, town, or village where you currently reside the same as the city, town, or village stated on the coupon? ‫ ڧ‬yes‫ ڧ‬noDD, date of 2nd time:MM/DD)

Have you read the "Instructions for the COVID-19 vaccine" and do you understand the effects and adverse side‫ ڧ‬yeseffects?
Do you fall into one of the target groups that have a higher priority for this vaccine?
‫ ڧ‬Medical personnel, etc.‫ ڧ‬Person 65 years or older ‫ ڧ‬Person 60 to 64 years old ‫ ڧ‬Worker at a senior citizen‫ ڧ‬yesfacility, etc.
‫ ڧ‬Person with an underlying disease (name of disease:)
Are you currently suffering from any kind of illness and receiving treatment or medication?
Name of disease: ‫ ڧ‬heart disease ‫ ڧ‬kidney disease ‫ ڧ‬liver disease ‫ ڧ‬blood disease ‫ ڧ‬disease that makes it
difficult to stop bleeding ‫ ڧ‬immune deficiency‫ ڧ‬yes‫ ڧ‬other ()Nature of treatment:‫ ڧ‬blood-thinning medicine () ‫ ڧ‬other ()Has a doctor who is treating you for the disease told you that you can have the vaccine today?

‫ ڧ‬no‫ ڧ‬no‫ ڧ‬no‫ ڧ‬yes‫ ڧ‬noHave you had a fever or gotten sick in the last month? Name of disease () ‫ ڧ‬yes‫ ڧ‬no

Are there any parts of your body that are not feeling well today? Condition ()‫ ڧ‬yes‫ ڧ‬noHave you ever had a convulsion (seizure)?

‫ ڧ‬yes‫ ڧ‬noHave you ever experienced severe allergic symptoms (such as anaphylaxis) from medications or foods?
Medication or food that caused the problem ()‫ ڧ‬yes‫ ڧ‬no‫ ڧ‬yes‫ ڧ‬noIs there any possibility that you are currently pregnant (for example, your period is later than expected)? Or are‫ ڧ‬yes
you breastfeeding?

‫ ڧ‬noHave you had any vaccines within the last two weeks?
Type of vaccine (‫ ڧ‬yes‫ ڧ‬no‫ ڧ‬yes‫ ڧ‬noHave you ever been sick after receiving a vaccine?
Type of vaccine () Condition ()) Date of vaccine ()Do you have any questions about the vaccine today?
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to the patient.
by doctor

Field filled in by doctor

Signature and seal of doctor

Ƒ7KHSHUVRQWREHYDFFLQDWHGLVXQGHU\HDUVROG ILOOLQLIDSSOLFDEOH 

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?
Ƒ,ZLVKWREHYDFFLQDWHGƑ,GRQRWZLVKWREHYDFFLQDWHG The purpose of this preliminary medical examination form is to ensure
the safety of the vaccine.
I understand this and consent to this prevaccination Screening
Questionnaire being submitted to the municipal government, the AllJapan Federation of National Health Insurance Organizations,and the National Health Insurance Organization.

Field filled in by doctor

Name of vaccine and lot number

Inoculation amount(*If the person to be vaccinated is unable to sign the form by himself/herself, a representative must sign the form, and therepresentative'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 the case of an adult ward, theform must be signed by the person himself/herself or the adult guardian.)

Vaccination location, name of doctor, and date of vaccination

Vaccination location

Seal position*Paste it straightly along with theframe.
(Note: Make sure that the expiration date
has not expired.)

Date:

Name of doctorml

Signature ofvaccinated personor their guardian*Please fill in the medical institution code and vaccination date so that they fit within this field.

Medical institution code

Date of vaccination*Example: April 1, 2021 Ѝ2021/04/01