Medical Questionnaire

 


 
Yes No

Was your child born at full term?

o

o

If no, at what gestation?                                                                                  ............ weeks

Was it a normal delivery?

o

o

Has your child ever had an adverse reaction to a vaccine in the past?

o

o

Has your child received any other vaccinations in the past 4 weeks?

o

o

Has your child had any serious illness in the past?

o

o

If so, briefly what?.......................................................................................

   

Has your child been treated with steroid tablets or drugs for cancer?

o

o

If so, when?                                                                                                      ......./......./.......

Does your child have an egg allergy?

o

o

Please list any other allergies your child may have:

 

 

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Signed.........................................................................     Dated:    ...….../.....…./.....…..

 

Child’s Name..............................................................     D.O.B:    ...….../.....…./.....…..