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Get Sample Questionnaire On Immunization

Immunization Screening Questionnaire / Authorization Form for Children under 18 years of age Child s name Date of birth // Yes No Don t Know 1. Is the child sick today o 2. Does the child have allergies to medications food or any vaccine 3. Has the child had a serious reaction to a vaccine in the past problem or had x ray treatments in the past 3 months 7. Has the child received a transfusion of blood or blood products or been given a medicine called immune gamma globulin in the past year 8. Is the child/teen pregnant or is there a chance she could become pregnant during the next month The parent or legal guardian of the child receiving immunization s must complete the following Parent or Legal Guardian Name of person bringing child to take my child born on Name of child for immunization s. Signature Must be signed by parent or legal guardian Date // Address Apt City Zip Code Telephone Fresno County Department of Public Health Source Immunization Action Coalition March 2010. Is the child sick today o 2. Does the child have allergies to medications food or any vaccine 3. Has the child had a serious reaction to a vaccine in the past problem or had x ray treatments in the past 3 months 7. Has the child received a transfusion of blood or blood products or been given a medicine called immune gamma globulin in the past year 8. Has the child received a transfusion of blood or blood products or been given a medicine called immune gamma globulin in the past year 8. Is the child/teen pregnant or is there a chance she could become pregnant during the next month The parent or legal guardian of the child receiving immunization s must complete the following Parent or Legal Guardian Name of person bringing child to take my child born on Name of child for immunization s. Is the child/teen pregnant or is there a chance she could become pregnant during the next month The parent or legal guardian of the child receiving immunization s must complete the following Parent or Legal Guardian Name of person bringing child to take my child born on Name of child for immunization s. Signature Must be signed by parent or legal guardian Date // Address Apt City Zip Code Telephone Fresno County Department of Public Health Source Immunization Action Coalition March 2010. Is the child sick today o 2. Does the child have allergies to medications food or any vaccine 3. Has the child had a serious reaction to a vaccine in the past problem or had x ray treatments in the past 3 months 7. Has the child received a transfusion of blood or blood products or been given a medicine called immune gamma globulin in the past year 8. Is the child/teen pregnant or is there a chance she could become pregnant during the next month The parent or legal guardian of the child receiving immunization s must complete the following Parent or Legal Guardian Name of person bringing child to take my child born on Name of child for immunization s. Has the child received a transfusion of blood or blood products or been given a medicine called immune gamma globulin in the past year 8. Is the child/teen pregnant or is there a chance she could become pregnant during the next month The parent or legal guardian of the child receiving immunization s must complete the following Parent or Legal Guardian Name of person bringing child to take my child born on Name of child for immunization s. Signature Must be signed by parent or legal guardian Date // Address Apt City Zip Code Telephone Fresno County Department of Public Health Source Immunization Action Coalition March 2010.

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