Hib（ヒブ） vaccine: Vaccination Register and Screening Questionnaire
Address

ア First round – First time
イ First round – Second time
※those who have received the first vaccination by
12month of age.
ウ First round – Third time
※those who have received the first vaccination by 7monthof age.
エ Booster vaccination※those who have received the first vaccination by
12month of age.

北区M・F

Patient's name

Parent/guardian nameDate of birth:
Age:

years

monthsPhone※ Second- and Third-time vaccination should be given by the age of12months and not given if the age is exceeded. (Booster vaccination is possible)
First time vaccination

Vaccination history (yyyy/mm/dd)
First vaccination received (yearsmonths)(//

Second time vaccination)(//

Third time vaccination)(Please fill in the question items in the bold box below and circle one of the answer columns.

//Booster vaccination)

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?

2.

Please answer about your child’s development history.

Doctor's commentNo

Yes

Did the child have abnormal findings at delivery?

Yes

No

Did the child have any abnormal findings after birth?

Yes

NoYes

No

Yes

NoYes

NoYes

No

Yes

No

Yes

No

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

Yes

No

8.

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

Yes

No

9.

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

Birth weight () gram

Have you ever been told any abnormal findings at an infant health check?
3.

Is the child sick today?
If so, describe the specific symptoms. ()4.

Did the child have a disease within the last one month? Name of disease ()5.

Has any family member or friend of the child had disease such as measles, rubella, chickenpox or mumps within one month?
Name of disease: (6.

)

Has the child been vaccinated in the past month?
Name of vaccination (7.

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?

Name of disease ()

Yes

No

Did the child have a fever at that time?

If Yes:age () years old.

Yes

No

10.

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

Yes

No

11.

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

Yes

No

12.

Has the child ever become ill after the vaccination?

Yes

No

13.

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

Yes

No14.

Do you have any question about the vaccination?

Yes

No

医師記入欄
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。

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。
医師署名又は記名押印
Entry column for parent/guardian:

使用ワクチン

I have been interviewed and explained by the doctor.

Lot No.

I have understoodthe benefit, objectives, and risk of serious side effects, and also the Relief（注）有効期限が切れていないか要確認

System for Health Damage by Vaccination. Now, I confirm my intent onAgree・Not agree)〒114-0003
東京都北区豊島 5-5-5-107としま町クリニック

接種量

taking vaccination as follows.
(実施場所・接種医師名
実施機関名・住所・電話番号

電話 03-3927-3778

0.5 mL

This screening questionnaire is used to improve the safety of vaccination.
I understand the above and agree that this questionnaire can besubmitted to the City.
Signature of Parent/Guardian or Companion

接種部位（皮下）
左・
右上腕大腿

接種医師名

接種（予診）年月日

年月日