Patient Health Questionnaire

Name of Patient (Pangalan)*

First NameLast Name

Date of Birth (Kapanganakan)*

MonthDayYear

Email*

example@example.com

Address (Tirahan)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender (Kasarian)*

Female (Babae)Male (Lalaki)

Primary Care Physician (Duktor)*

Clinic Address of your Doctor (Klinika ng Duktor mo)*

Contact Number (Telepono)*

I want to receive the following vaccine/s today (Bakuna na nais matanggap ngayon):*

Influenza (Flu) VaccinePneumococcal Vaccine

The following questions will help us determine your eligibility to receive the vaccine requested. Please put an (X) on the appropriate column for your answers. (Ang mga sumusunod na katanungan ay makakatulong sa amin upang malaman kung nararapat na kayo ay tumanggapng bakuna ngayon. Pakisulat ang (X) para sa kasagutan sa bawat tanong.)*

	Yes (Oo)	No (Hindi)
1. Are you sick today? (Do you have fever, nausea, vomiting or diarrhea?). Masama ba ang iyong pakiramdam ngayon? (Ikaw ba ay nilalagnat, nahihilo, nagsusuka or nagtatae?)
2. Do you have allergies to food, medication, or vaccines?. Ikaw ba ay may allergy sa pagkain, gamot or vaccine?
3. Have you ever had a reaction after receiving a vaccine including fainting or feeling dizzy?. Ikaw ba ay nakaranas ng reaksyon katulad ng pagkahilo o hinimatay pagkatapos mabigyan ng vaccine?
4. Are you currently on treatment for any long-term health problem (heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?. Ikaw ba ay kasalukuyang naggagamot para sa isang pang matagalan na karamdaman (katulad ng sakit sa puso,baga, bato, metabolic disease (diabetes), anemia or iba pang sakit sa dugo?
5. Are you currently on treatment for cancer, leukemia, HIV/AIDS, or any other immune system problem?. Ikaw ba ay kasalukuyang naggagamot para sa cancer, leukemia, HIV/AIDS, o iba pang sakit ng immune system?
6. In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; or have you had radiation treatment?. Sa nakalipas na 3 buwan, uminom ka ba ng kahit anong gamot na nakakaapekto sa inyong immune system katulad ng prednisone, iba pang steroids, o gamot laban sa cancer, o ikaw ba ay sumailalaim sa radiation therapy?
7. Do you have a history of Guillain-Barre Syndrome?. Ikaw ba ay may o nakaranas ng Guillain-Barre Syndrome?
8. Have you had a seizure, or a brain or other nervous system problem?. Nakaranas ka na ba ng seizure, or ikaw ba ay may ibang sakit sa utak o nervous system?
9. During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?. Sa loob ng nakaranng taon, ikaw ba ay nasalinan ng dugo o iba pang blood products, o tumanggap ka ba ng immune (gamma) globulin o gamot laban sa virus (antiviral)?
10. For women: are you pregnant or is there a chance you could get pregnant within the next month?. Para sa mga kababaihan: Ikaw ba ay nagdadalang-tao o may pagkakataon na mabuntis sa loob ng susunod na buwan?
11. Have you received any vaccinations in the past 4 weeks?. Ikaw ba ay tumanggap ng kahit na anong bakuna sa nakaraang 4 na lingo?

(Screening Checklist for Contraindications to Vaccines for Adults. (2016). https://www.immunize.org/catg.d/p4065.pdf)

Patient Consent to Vaccination

I have received, read, and/or had explained to me the Vaccine Information Statement (VIS) on Influenza/Shingles vaccine that I have chosen to receive today. I have had the chance to ask questions, which were answered to my satisfaction. I understand the benefits and risks of the vaccination and understand it is not possible to predict all possible side effects or complications associated with the vaccination. I agree to remain in the vaccination area or the pharmacy for 15 minutes for monitoring. I believe the benefits outweigh the risks and voluntarily assume full responsibility for any reactions that may result and hereby release the pharmacist, the company, its officers and employees from any liability in connection with immunization(s).

(Nabasa ko at naipaliwanag sa akin ang nilalaman ng Vaccine Information Statement (VIS) tungkol sa bakuna para sa Influenza/Shingles na nais kong matanggap sa araw na ito. Naintindihan ko kung bakit ako babakunahan at ang mga kaakibat nitong benepisyo sa aking kalusugan, ganoon din ang mga maari kong maramdaman o posibleng komplikasyon nito. Naiintindihan ko na mas maraming benepisyo ang mabakunahan kung ihahantulad ito sa mga panganib sa kalusugan nang hindi mabakunahan. Nabigyan ako ng pagkakataong makapagtanong o liwanagin ang mga hindi malinaw sa akin at nasagot at naipaliwanag naman ito sa aking kasiyahan. Ako ay sumasang-ayon na manatili sa botika o pharmacy sa loob ng labinlimang minute (15 minutes) para masubaybayan ng pharmacist ang epekto ng pagbabakuna. Matapos ito, responsibilidad ko ang anumang reaksyon na maaring mangyari sa akin at walang pananagutan ang pharmacist ganoon din ang kumpanya ng botika kaugnay sa pagbabakunang ito. )

Please upload a picture of your signature over your printed name, or your parent or guardian's signature over printed name.

Date*

MonthDayYear

Take Photo*

Vaccine Administration and Patient Consent Form