Rotavirus（ロタウイルス）vaccine: Vaccination Register and Screening Questionnaire
Address

北区M・F

Patient's name

Parent/guardian nameDate of birth:Age:yearsmonths

Phone□ First time vaccination(RotarixRV１・ RotaTeq RV5)

Vaccination history - Mark✔on the box.
Circle type of vaccination you took.
Fill in the date of previous vaccination

YearMonth□ Second time vaccination(RotarixRV１・ RotaTeq RV5)

DayYearMonthア

１回目

イ

２回目

ウ

３回目

□

Third time vaccination(RotaTeq RV5)Day

※If this is the first time make sure that today is not past14weeks and 6days after birth.
※If you are unsure of the vaccination, you have received so far, show your doctor the record of your vaccination in the maternal and child Health handbook or vaccination record sheet orcheck with the medical institution that you vaccinated last time.
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?

No

Yes

2.

Did you understand the effects and side reactions of vaccination today?

No

Yes

3.

Were you explained about an intussusception and understand it?

No

Yes

4.

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

Yes

No

Yes

No

Yes

No

Yes

No

Did the child have a fever at that time?

Yes

No

14.

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

Yes

No

15.

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

Yes

No

16.

Has the child ever become ill after the vaccination?

Yes

No

17.

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

Yes

No

18.

Did the mother receive any immunosuppressive medications during her pregnancy?

Yes

No

19.

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?
5.

Is the child sick today?
If so, describe the specific symptoms. ()6.

Did the child have a disease within the last one month?

7.

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

Name of disease ()Name of disease: (8.

Doctor's comment)

Has the child been vaccinated in the past month?
Name of vaccination (Date of vaccination;/)9.

Has the child had an intussusception in the past?

10.

Are there congenital gastrointestional disorders that have not been treated? ※ If Yes, the child cannot take vaccination.

※ If Yes, the child cannot take vaccination.

11.

Has the child ever been diagnosed with an immune deficiency, had infectious disease such as pneumonia or otitis media, had repeated12.

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

diarrhea, or had a poor weight gain?
have consulted a doctor?

Name of disease ()Has the doctor treating disease told you that the child could have the vaccination today?
13.

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

If Yes:age () years old.

Name of medicine()

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.

該当に✔してください

I have understoodthe benefit, objectives, and risk of serious side effects, and also the Relief
System for Health Damage by Vaccination. Now, I confirm my intent on□ロタリックス（１価）1.5mL□ロタテック（５価）2mL

Lot No.

〒114-0003
東京都北区豊島 5-5-5-107としま町クリニック

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

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
to the City.
Signature of Parent/Guardian or Companion

電話 03-3927-3778)（注）有効期限が切れていないか要確認

接種医師名
経口接種
接種（予診）年月日

年月日