[Form No. 1]
                        Immunization Screening Questionnaire
  To ensure safe vaccinations, please read the following questions carefully and mark Patient/Parent or
                                            Legal Guardian as appropriate.
     Name                                         Resident Registration Numbers              -           (☐Male ☐Female)
 Date of Birth
(YYYY.MM.DD)                                      Foreign Registration Number                -           (☐Male ☐Female)
Telephone          (Home)                    (Cell Phone)                               Weight                           kg
                                                                                                  Patient/ Parent or Legal
                      Release of Personal Vaccination Information                                 Guardian ☑
We collect personal information including Foreign Registration Number and Sensitive Information in accordance with
 the “INFECTIOUS DISEASE CONTROL AND PREVENTION ACT” Article 24, 32 and the “ENFORCEMENT DECREE
 OF THE INFECTIOUS DISEASE CONTROL AND PREVENTION ACT” Article 32-3. The additional personal
 information to be collected is as follows:
   □ Personal information collection·processing purpose: sending reminder messages regarding upcoming
       vaccination dates, confirmation messages for received vaccinations, and messages regarding the
       monitoring of adverse events following immunization.
   □ Personal information collection·processing category: personal information(including Foreign Registration Number and
      Sensitive Information), telephone(home, cell phone)
   □ Period of retention and use: 5 years
I hereby consent to the release of my child's (my) vaccination records through the
Immunization Registry Information System (IRIS).                                                     ☐ Yes ☐ No
  * Denying consent could lead to unnecessary vaccinations or cross vaccinations.
I hereby consent to receiving reminder messages for upcoming vaccinations and
confirmation of received vaccinations.
 * Denying consent will result in no longer receiving information on upcoming or received              ☐ Yes ☐ No
 vaccinations.
I hereby consent to receiving messages for the monitoring of adverse events following
immunization.
 * Denying consent will result in no longer receiving information on adverse events following          ☐ Yes ☐ No
 immunization.

                                                                                                    Patient/ Parent or Legal
                         Pre-Immunization Screening Checklist                                       Guardian ☑
 Are you feeling sick today? If yes, please describe any symptoms.
 (                                                                                 )                   ☐ Yes ☐ No
 Have you ever experienced an allergic reaction such as urticaria or rash to certain
 medications, foods (especially eggs), or vaccinations?                                                ☐ Yes ☐ No
 Have you ever experienced any adverse events following vaccination in the past? If yes,
 please specify the vaccine. (                                                           )             ☐ Yes ☐ No
 Have you ever been diagnosed with or treated for congenital anomaly, asthma, lung, heart,
 kidney, or liver problems, metabolic diseases (e.g. diabetes), or blood disorders? If yes,            ☐ Yes ☐ No
 please specify.(                                                                          )
 Have you experienced seizures or other nervous system disorders (e.g. Guillain-Barre syndrome)?       ☐ Yes ☐ No
 Do you have cancer, hematologic diseases, or any other immune system problem? If yes,
 please describe. (                                                )                                   ☐ Yes ☐ No
 In the past three months, have you taken cortisone, prednisone, other steroids or anti-cancer
 drugs, or had radiation treatment?                                                                    ☐ Yes ☐ No
 In the past year, have you ever received a blood transfusion or immunoglobulin?                       ☐ Yes ☐ No
 Have you received any vaccinations within the past month? If yes, please specify.
 (                                                                     )                               ☐ Yes ☐ No
 (For women) Are you pregnant or is there a chance of becoming pregnant within the next month?         ☐ Yes ☐ No
 I hereby confirm that I have been informed of my examination results and of the potential adverse events following
 immunizations (AEFIs), and hereby agree to receiving vaccination(s).
 Patient or Parent/Legal Guardian:
 (Name)                                (Signature)                            (Relationship to patient)
 * National Registration Number of legal guardian (if your child’s birth has not yet been registered):       -
                                                                        Date:     (yyyy)      (mm)      (dd)

            Results of Pre-Vaccination Screening (to be completed by a physician)                               Check ☑
 Body temperature :             ℃       I have explained about possible risks of immunization (AEFI)                ☐
                                                                                                                    ☐
 I have explained that the vaccine recipient should stay at the medical institution for 20~30 minutes for observation.
 Results of history-taking :
 Based on the patient’s history and physical examination, the vaccine recipient is able to receive vaccinations.
 Physician (Name):                                      (Signature)
                                                                                            210㎜× 297㎜(보존용지(2종) 70g/㎡)