Annex D

Quick Health Assessment Form For MR Vaccine

Name of the Child Date of Birth (mm/dd/yyyy)
Surname: First Name: Middle Name:

Address Age Sex

House Number: Purok/Sitio:

Barangay: City:

Contact Number: Name of Barangay Health Center:

QUICK HEALTH ASSESSMENT

Mark all appropriate spaces/boxes with a check ()
Questions Yes No Decision Remarks
If Yes, DEFER
vaccination; refer
1. Does the child have fever for medical
( 37.6 ? management; and
set a define date for
the vaccination
2. Does the child have a history of
severe allergy to the previous
If Yes, DO NOT
injectable vaccines or measles-
GIVE the MCV
containing vaccine?
Specify all known allergies:
3. Does the child have any of the If Yes, DO NOT
following conditions: GIVE the MCV
Severe illness
Active TB
Primary immune-deficiency disease
Suppressed immune response from
medications
Leukemia
Lymphoma
Other generalized malignancy

Note: Malnutrition, low-grade fever, mild respiratory infections, diarrhea and other minor illnesses should not be a
contraindication.

Immunization card available? Yes No

Assessed by: Confirmed and approved for vaccination:

Signature over printed name of the health Signature over printed name of the
worker/screener Parent/Guardian
Date (mm/dd/yyyy): Date (mm/dd/yyyy):