PART A: PERSONAL PARTICULARS
PART B: MEDICAL INFORMATION
PART B1: FEVER & VACCINATION
Have you had a fever or any vaccination recently?
PART B2: IMMUNOCOMPROMISE (additional counselling will be required before vaccination)
Do you have any medical conditions causing severe immunocompromise?
PART B3: ALLERGIES
Have you ever had any severe allergic reactions to vaccines, medications or insect stings?
PART B4: OTHER PRECAUTIONS (CAN STILL VACCINATE)
Are you currently taking these medications or have these medical conditions?
PART B5: PREGNANCY & RELATED QUESTIONS (FOR FEMALES ONLY)
PART C: PATIENT DECLARATION AND CONSENT