| Results of Pre-Vaccination Screening (to be completed by a physician) | Results of Pre-Vaccination Screening (to be completed by a physician) | Check ☑ | - (☐Male ☐Female) | - (☐Male ☐Female) |
| Body temperature : ℃ | I have explained about possible risks of immunization (AEFI) | ☐ | - (☐Male ☐Female) | - (☐Male ☐Female) |
| I have explained that the vaccine recipient should stay at the medical institution for 20~30 minutes for observation. | I have explained that the vaccine recipient should stay at the medical institution for 20~30 minutes for observation. | ☐ | Weight | kg |
| Results of history-taking : | Results of history-taking : | Results of history-taking : | | |
| 210㎜× 297㎜(보존용지(2종) 70g/㎡) | Based on the patient’s history and physical examination, the vaccine recipient is able to receive vaccinations. Physician (Name): (Signature) | Based on the patient’s history and physical examination, the vaccine recipient is able to receive vaccinations. Physician (Name): (Signature) | | |
| Pre-Immunization Screening Checklist | Patient/ Parent or Legal 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, please specify.( ) | ☐ Yes ☐ No | | | |
| 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) | 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) | | | |