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to Information PackMEDICAL QUESTIONNAIRE
Was your child born at full term?
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If no, at what gestation? ............ weeks
Was it a normal delivery?
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Has your child ever had an adverse reaction to a vaccine in the past?
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Has your child received any other vaccinations in the past 4 weeks?
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Has your child had any serious illness in the past?
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If so, briefly what?.......................................................................................
Has your child been treated with steroid tablets or drugs for cancer?
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If so, when? ......./......./.......
Does your child have an egg allergy?
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Please list any other allergies your child may have:
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Signed......................................................................... Dated: ... .../..... ./..... ..
Childs Name.............................................................. D.O.B: ... .../..... ./..... ..