预防接种申请单.pdf

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2017-03-22 发布于四川
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预防接种申请单.pdf

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预防接种申请单

预防接种申请单 BJZ-048 预防接种预防接种联系电话（周一至周五8：00- 15：30,国定假日除外） 021021021 Tel :( Monday to Friday 8 :00- 15 :30,N ational holiday s excluded) :A 预防接种记录单 BJZ-048 预防接种申请单未成年人(18岁) BJZ-048 A pplicat ion Form and Screening Quest ionnaire for Children and Adolescents Immunizat ion ( 18years) Is your child sick today ? Has your child ever had a seriou s reaction after receiving a vaccination ? Does the child have allergies to medication s, food (eggs ect .),or any vaccine? Has your child received any vaccination s in the past four week s? Does your child,or any per son who lives with or takes care of him/her, have cancer,leukemia,AID S,or any other immune sy stem problem ? Is your child ,or any per son who lives with or takes care of him/her,taking cortisone,prednisone,other steroids,anticancerdrugs,or radiation treatment s ? During the past One year,has your child received a tran sfu sion of blood or plasma,or any treatment of immunoglobulin ? Does your child have epilep sia or any other neurop sychical sy stem problem s?