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2021-08-02 19:37:23
During this period, people have been vaccinated against Covid-19 according to the distribution of vaccines in provinces and cities across the country and we can register for Covid-19 vaccination in many different forms, such as registering at the place of residence using the registration form for Covid-19 vaccination, registering for Covid-19 vaccination via the electronic health book application, registering for Covid-19 vaccination on the website.
Currently, residential groups, or companies will distribute applications for Covid-19 vaccine to each person and collect them to transfer to the competent authorities, assess and classify the group of people injecting according to regulations. government. You can use the application form for Covid-19 vaccine by following the download link below.
Registration form for Covid-19 vaccine number 1
VIETNAM SOCIAL REPUBLIC OF VIETNAM
………… Independence – Freedom – Happiness
PRIVACY SCREEN FOR COVID-19 VACCINATION
First and last name:………………………………………………………. Male Female
Date of birth……………….………………………………………………… ……….
Job:……………………………………………………………………..
Work unit: ……………………………………… …………………………… …..
Address: ……………………………………….. ..Phone number: ……………………………………
|
1. Current acute illness |
No |
Yes |
|
2. History of allergy (specify)……………………. |
No |
Yes |
|
3. History of anaphylaxis grade 2 or higher with any agent |
No |
Yes |
|
4. History of other vaccinations in the past 14 days |
No |
Yes |
|
5. History of COVID-19 within 6 months |
No |
Yes |
|
6. History of plasma treatment from a cured patient COVID-19 or immunoglobulin within 90 days |
No |
Yes |
|
7. History of immunosuppression, cancer, splenectomy, current use immunosuppressants, high-dose corticosteroids (equivalent to or more than 2 mg prednisolone/kg/day for at least 7 days) |
No |
Yes |
|
8. History of blood clotting/hemostasis disorder or taking medication Antifreeze |
No |
Yes |
|
9. Pregnant, breastfeeding women |
No |
Yes |
|
10. Abnormal vital signs (specify) • Temperature: degrees Celsius • Pulse: times/minute • Blood pressure: mmHg • Breathing rate: times/minute; SpO2: % (if any) |
No |
Yes |
|
11. Abnormal signs when listening to the heart and lungs |
No |
Yes |
|
12. Perceptual disturbances |
No |
Yes |
Conclusion:
Eligible for immediate vaccination (All with NO abnormalities)
Contraindications to vaccination of the same type (When there is an abnormality in item 3)
Delayed vaccination (When there is any abnormality in items 1, 4, 5, 6, 7, 8, 9) □
Transfer vaccination and follow-up at the hospital (When YES in items 2, 10, 11, 12)
It is recommended to move to …………………………………………………….
Reason: ………………………………………………………………………………………………
………..hour …..minute, date….month …..year 2021
The person doing the screening
(signature, write full name)
Registration form for Covid-19 vaccine No. 2
REGISTRATION FORM FOR COVID-19 VACCINE
1. ADMINISTRATIVE INFORMATION:
Full name of person applying for injections
:……………………Gender: Male / Female
Date of birth
:……………………
ID/CCCD number: ………………..………… Health insurance code:………………
Contact phone number
:………………… Email :………………………
Current residential address
: House number/Apartment number/Building…….street….
Residential group: ……, ward…, district…. Hanoi
Occupation: …………………… Work unit……………………..
2. IMPORTANT REGISTRATION INFORMATION:
|
Vaccination registration place: …………………… Ward…………………….. |
Vaccination registration time: ………………/ Vaccination time (time frame):….. |
Register for the second injection: 1 2 |
|
3. DECLARATION OF HEALTH CONDITION BEFORE IMPORTING THE VACCINES FOR COVID-19: |
1. History of anaphylaxis grade 2 or higher (If any, type of allergic agent…) |
No |
|
Yes |
2. History of COVID-19 within 6 months |
No |
|
Yes |
3. History of other vaccinations in the past 14 days (If any, type of vaccine…) |
No |
|
Yes |
4. History of immunocompromised, terminal cancer, splenectomy, immunosuppressive drugs, high-dose corticosteroids (equivalent to or more than 2mg predinisolon/kg/day for at least 7 days) (if any, bring the prescription to the vaccination point for medical staff to check and screen when going to vaccinate at the injection site) |
No |
|
Yes |
5. History of chronic disease that is progressing (If any, type of disease…), (if any, bring prescriptions to the vaccination site for medical staff to screen when they come to vaccinate at the injection site) |
No |
|
Yes |
6. Acute illness (If any, type of disease…), (if any, bring prescriptions to the vaccination site for medical staff to check and screen when immunizing at the injection site) |
No |
|
Yes |
7. Pregnant, breastfeeding women |
No |
|
Yes |
8. Age: 65 years old |
No |
|
Yes 9. History of coagulation/hemostasis disorder or taking anticoagulants No Yes 10. Abnormal vital signs (specify) |
• Temperature: degrees Celsius |
• Pulse: times/minute |
|
• Blood pressure: mmHg |
• Breathing rate: times/minute; SpO2: % (if any) |
No |
|
Yes |
11. Abnormal signs when listening to the heart and lungs |
No |
|
Yes |
12. Perceptual disturbances |
No |
|
Yes |
13. Have you been vaccinated against COVID-19? (if yes, number of shots given…….Vaccine type…………..) |
No |
Yes
14. Reactions after the previous vaccination against COVID-19 (describe clearly the screening examination by health workers when they come to vaccinate)
No
Yes
Hanoi, date ….month …..year 2021
Declarants
Register for Covid-19 vaccine
Covid-19 vaccine registration form
Download registration form for Covid-19 vaccine
Download the Covid-19 vaccine application form
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