Registration form for Covid-19 vaccine

Registration form for Covid-19 vaccine

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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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