Mumps（おたふくかぜ） vaccine: Vaccination Register and Screening Questionnaire
AddressPhoneM

Patient's nameDate of birth (yyyy/mm/dd):・F
Parent/guardian nameAge:

Please fill in the question items in the bold box below and circle one of the answer columns.

years

monthsBody temperature before interview

Questionnaire for Vaccination℃

AnswerDoctor'scomment1.

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

NoYes

2.

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

NoYes

NoYes

No

Yes

No

Yes

No

Yes

No

Did the child have a fever at that time?

Yes

No

9.

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

Yes

No

10.

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

Yes

No

11.

Has the child ever become ill after the vaccination?

Yes

No

12.

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

Yes

No

13.

Have you received blood transfusions or gamma globulin within 6 months?

Yes

No

14.

Women only :

Yes

No

15.

Do you have any question about the vaccination?

Yes

NoBirth 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 ()Has the doctor treating disease told you that the child could have the vaccination today?
8.

)

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

Are you pregnant now?

If Yes:age () years old.

※If not, please avoid pregnancy for 2months after vaccination.

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

使用ワクチン

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

I have understood〒114-0003

the benefit, objectives, and risk of serious side effects, and also the Relief

東京都北区豊島 5-5-5-107

System for Health Damage by Vaccination. Now, I confirm my intent on（注）taking vaccination as follows.
(有効期限が切れていないか要確認Agree・

Not agree)

接種量

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

実施場所・接種医師名
実施機関名・住所・電話番号

Lot No.としま町クリニック
電話 03-3927-3778

0.5 mL
接種部位（皮下）
左・
右

接種医師名
上腕伸側部

接種（予診）年月日

年月日※ Gamma globulin is a blood product that is injected to prevent infections, such as type A hepatitis, and to treat severe infections. Certain vaccines (live attenuated vaccine; for example,measles vaccine) are occasionally less effective in people who have received this product in the preceding 3 to 6 months.