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SENDAGAYA INTERNATIONAL CLINIC

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Questionnaire for a preliminary examination before vaccination with the influenza HA vaccine
Appointment Form
When do you want to
see the doctor?  ※
  (dd/mm/yyyy)
At what time do you
want an appointment?  ※
Name ※ Family name       Given name   
Date of birth ※   (dd/mm/yyyy)
Sex ※   Male      Female
Address ※ 〒 Postal code :
Occupation ※
E-mail ※
Cellular phone number  ※
  (Telephone number)
cellular phone or to your e-mail ※ If we need to ask you something, would you like to be contacted to your cellular phone or to your e-mail address   cellular phone      e-mail       either one is OK
question.1  ※ At present, do you have a disease?   Yes   No Name of disease :   Are you receiving any medical treatment (drug or other)?   Yes   No Do you have a permission to receive today's preventive vaccination by the physician in charge of your disease?   Yes   No
question.2  ※ Have you ever had any chronic disease (congenital anomalies, cardiac, renal, hepatic, cranial nerve disease, immunodeficiency, blood diseases, other)?   Yes   No Name of disease :  
question.3  ※ Have you ever had a rash or urticaria, or did you become ill due to drags of food (especially, egg,poultry, food originating from poultry)?   Yes   No  
question.4  ※ (1)Have you ever received an influenza vaccination?   Yes    No (2) At that time, did you become ill after?   Yes    No (3) Did you ever become ill afterr when receiving a vaccine other than influenza?   Yes   No Name of vaccine:  
question.5  ※ Did you receive any vaccinations within the last four weeks?   Yes   No Name of the vaccination :   
question.6  ※ Do you have a history of convulsions?   Yes   No  
question.7  ※ Have you ever been diagnosed with a respiratory disease such as interstitial pneumonia or bronchial asthma?   Yes   No  
question.8  ※ Have any of your family or friends been infected with measles, rubella, or mumps in the last month?   Yes    No Name of disease(s):   
question.9  ※ (For female patients) At present, are you pregnant?   Yes   No  
question.10 (For Children) growth history of child: Body weight at birth:    Did your child have any abnormalities at birth?   Yes   No Did your child develop any abnormalities after birth?   Yes   No Have you ever been told of any abnormalities at infant examinations?   Yes   No
Others Do you have any questions about the vaccination?
Inoculation  ※ I understand the risks and side-effects associated with the vaccines I wish to take as explained by the doctor, and decide to   get vaccinated     not get vaccinated