预防接种申请表格.docVIP

疫苗接种或预防措施申请书 Application Form for Vaccination or Prophylaxis 申请人姓名 性别 Applicant’s name Sex 出生年月日 国籍 前往国家 Date of birth Nationality Departure to 职业 证件号码: Occupation Passport No. 如带有既往免疫接种纪录，请出示。 If you have brought your vaccination record with you, please show it. 请如实回答下列问题，并在相应的□内打钩“√”标记，这些问题将有助于医生决定您是否适宜接种疫苗。 The following questions will help us determine whether you are adequate to be vaccinated. Please answer these questions by checking the boxes. 目前是否有发热、结核病、糖尿病、高血压病、免疫缺陷症、严重的心、脑、肝、肾疾病、恶性肿瘤、血液疾病、自身免疫病、心理障碍等疾病？ Do you have fever, TB, diabetes, hypertension, immunodeficiency, severe heart, liver or kidney disease, malignancy, hematologic disease, auto-immune disease, psychological obstacle ,etc? 是Yes 否No □ □ 是否有药物、食物（鸡蛋等）或疫苗接种过敏史或过敏症等？ Do you have allergies to medications, food (eggs , ect.) or to any vaccine ? □ □ 近三月内是否使用过免疫球蛋白、干扰素、胸腺肽、转移因子、免疫抑制剂等？是否曾经接受过放射或化疗？近期是否接种过狂犬、流脑或其它疫苗？ Have you been given immune globulin, IFN, thymic peptide, TF, immunodepressant , etc. within 3 months? Have you accepted any radiotherapy or chemotherapy? Have you been vaccinated against rabies, meningitis recently? □ □ 仅对成年女性要求回答，目前是否怀孕、哺乳，未来三个月是否有怀孕计划？ For woman, is it possible that you are pregnant or lactation, or may become pregnant in the next three months? □ □ 如果选项中有“是”，请详细说明。If “yes”, pleas describe in detail. 我保证以上所填内容是真实的，已经阅读并理解此页背面的《预防接种注意事项》，愿意接种下列疫苗产品。 By signature, I verify that information given in this form is true and accurate . I have rea