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Health Declaration Screening Form

This document is a health screening form for COVID-19 booster vaccination in the Philippines. It screens for [1] whether the recipient has already received a full vaccine series and booster, [2] any contraindications to receiving the vaccine such as allergies, recent COVID infection, pregnancy, or underlying conditions, and [3] the recipient's current symptoms, vitals, medical history and recent exposures. If any questions are answered "yes" then vaccination should be deferred and referred to a healthcare provider for further evaluation.

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fitch
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116 views1 page

Health Declaration Screening Form

This document is a health screening form for COVID-19 booster vaccination in the Philippines. It screens for [1] whether the recipient has already received a full vaccine series and booster, [2] any contraindications to receiving the vaccine such as allergies, recent COVID infection, pregnancy, or underlying conditions, and [3] the recipient's current symptoms, vitals, medical history and recent exposures. If any questions are answered "yes" then vaccination should be deferred and referred to a healthcare provider for further evaluation.

Uploaded by

fitch
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COVID-19 BOOSTER VACCINATION

HEALTH DECLARATION SCREENING FORM


of the Philippine National COVID-19 Vaccine Deployment and Vaccination Program as of
November 16, 2021

ASSESS THE PATIENT NO YES

Has received and completed the vaccine series of any COVID-19 vaccines AND has received an additional booster dose?
Completed vaccine series: ❏ ❏
➢ Two doses of Pfizer-BioNTech, Moderna, Sinovac, Gamaleya, AstraZeneca; or
➢ One dose of Janssen

If has received and completed two doses of Pfizer-BioNTech, Moderna, Sinovac, Sinopharm, Gamaleya, AstraZeneca, has it only been less than 6
months since then?
❏ ❏
Or, if has received and completed one dose of Janssen, has it only been less than 3 months since then?

Below 18 years old? ❏ ❏

Had a severe allergic reaction to any ingredient of the vaccine currently being offered? Or had a severe allergic reaction after receiving any COVID-19
vaccine? ❏ ❏

Has allergy to food, egg, medicines? Has asthma? ❏ ❏

➢ If with allergy or asthma , will monitoring the patient for 30 minutes be a problem? ❑ ❑

Has history of bleeding disorders or currently taking anti-coagulants? ❏ ❏

➢ If with bleeding history or currently taking anti-coagulants, is there a problem securing a gauge 23 - 25 syringe for injection? ❑ ❑

Has SBP >160 mmHg and/or DBP> 100 mmHg WITH signs and symptoms of organ damage? ❏ ❏

If initially with SBP >160 mmHg and/or DBP> 100 mmHg WITHOUT signs and symptoms of organ damage, is there a problem maintaining a blood
pressure of <160/100 mmHg after monitoring two times every fifteen minutes? ❏ ❏

Manifests any one of the following symptoms?


❑ Fever/chills ❑ Fatigue
❑ Headache ❑ Weakness
❑ Cough ❑ Loss of smell/taste ❏ ❏
❑ Colds ❑ Diarrhea
❑ Sore throat ❑ Shortness of breath/difficulty in breathing
❑ Myalgia ❑ Nausea/ Vomiting
❑ Rashes ❑ Other symptoms of existing comorbidity

Has history of exposure to a confirmed or suspected COVID-19 case in the past 14 days? ❏ ❏

If previously diagnosed with COVID-19, is recipient STILL undergoing recovery or treatment? ❏ ❏

Has received any vaccine in the past 14 days or plans plan to receive another vaccine 14 days following vaccination? ❏ ❏

Has received convalescent plasma or monoclonal antibodies for COVID-19 in the past 90 days? ❏ ❏

If in the 1st trimester of pregnancy, is there any objection to vaccination from the presented medical clearance from the attending physician? ❑ ❑

Has any of the following diseases or health condition?


❑ HIV
❑ Cancer/ Malignancy (currently undergoing chemotherapy, radiotherapy, immunotherapy, or other treatment)
❑ Underwent Transplant
❑ Under Steroid Medication / Treatment ❏ ❏
❑ Bed ridden, terminal illness, less than 6 months prognosis
❑ Autoimmune disease
❑ Myocarditis or pericarditis OR developed myocarditis/ pericarditis after a dose of mRNA vaccine

➢ If with any of the abovementioned condition, is there any objection to vaccination from presented medical clearance prior to vaccination
day? ❏ ❏

Recipient’s Name: Sex:

Parent’s/ Legal Guardian’s Name: Wt (kg) VACCINATE


If any of the white
Birthdate: BP: Temp:
boxes is checked,
Signature of Health Worker: HR: RR: O2 sat: DEFER vaccination

* Please keep this health screening form as part of the patient’s official vaccination and medical record.

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