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★は記入しないで下さい |
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インフルエンザ予防接種予診票 |
★ 接種日 |
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接種予約日 |
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何回目 |
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★ 接種量 |
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令和 年 月 日 |
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回目 |
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□ 3歳未満 0.25ml |
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午後 時 分 |
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□ 3歳以上 0.5ml |
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ふりがな |
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受ける人氏名 |
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年齢 |
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歳 |
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ヶ月 |
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保護者の氏名 |
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生年 |
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平成/令和 |
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年 |
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月日 |
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月 日 |
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住所 |
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性別 |
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□ 男 |
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電話番号 |
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□ 女 |
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質 問 事 項 |
診察前の体温 |
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度 |
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回答欄 |
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医師記入欄 |
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現在、何か病気にかかっていますか |
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病名（ ） |
はい |
いいえ |
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治療（投薬など）を受けていますか |
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薬名（ ） |
はい |
いいえ |
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その病気の主治医には、今日の予防接種を受けてよいといわれましたか |
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はい |
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いいえ |
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今日体に具合の悪いところがありますか |
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はい |
いいえ |
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具体的な症状を書いてください （ ） |
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最近1ヶ月以内に、家族や遊び仲間に、インフルエンザ、麻しん、風しん、水痘、 |
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はい |
いいえ |
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おたふくかぜなどの病気の方がいましたか |
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（病名 ） |
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最近1ヶ月以内に予防接種を受けましたか |
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はい |
いいえ |
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予防接種の種類（ ） |
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季節性インフルエンザ又は新型インフルエンザの予防接種を受けたことがありますか |
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はい |
いいえ |
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その際に具合が悪くなったことはありますか |
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はい |
いいえ |
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これまでにインフルエンザ以外の予防接種を受けて具合が悪くなったことはありますか |
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はい |
いいえ |
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予防接種の種類（ ） |
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ニワトリの肉や卵などにアレルギーがありますか |
はい |
いいえ |
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薬や食品で皮膚に発疹やじんましんが出たり、体の具合が悪くなったことがありますか |
はい |
いいえ |
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ひきつけ（けいれん）をおこしたことがありますか （ ）歳頃 |
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はい |
いいえ |
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そのとき熱が出ましたか |
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はい |
いいえ |
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近親者に予防接種を受けて具合が悪くなった方はいますか |
はい |
いいえ |
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今日の予防接種について質問がありますか |
はい |
いいえ |
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卵アレルギーがある場合、今まで卵を食べたことがない方、季節型インフルエンザワクチンで副反応が出た方、アナフィラキシーを起こした方は皮内反応を行います。 |
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★ |
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皮内反応 陽性 陰性 |
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mm x
mm |
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以上の問診及び診察の結果、今日の予防接種は （ 可能 ・ 見合わせる ） |
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本人に対して、予防接種の効果、副反応及び予防接種健康被害救済制度について、説明をした |
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医師署名又は記名押印 |
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医師の診察・説明を受け、予防接種の効果や目的、重篤な副反応の可能性などについて理解した上で、 |
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接種を希望しますか （ 接種を希望します ・ 接種を希望しません ） |
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保護者署名 |
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★ ロット番号 |
実施場所．医師名 |
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Lot No. |
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実施場所 |
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佐々木こどもクリニック 名古屋市名東区朝日が丘９９ グロリア朝日ヶ丘 |
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医師名 |
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佐々木邦明 |
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