HEALTH DECLARATION SCREENING FORM FOR SINOVAC

ofthePhilippineNationalCOVID-19VaccineDeploymentandVaccinationProgram
asofMarch10,2021

ASSESS THE PATIENT NO YES

Below 18 years old or above 59 years old? ❏ ❏

Has severe allergic reaction after the 1st dose of the vaccine? ❏ ❏

Has allergy to food, egg, medicines and/or asthma? ❏ ❏

➢ Ifwithallergyorasthma,willmonitoringthepatientfor30minutesbea ❑ ❑
problem?

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

➢ Ifwithbleedinghistoryorcurrentlytakinganti-coagulants,isthereaproblem ❑ ❑
securingagauge23-25syringeforinjection?

Manifests any of the following symptoms:

❑ Fever/chills ❑ Fatigue
❑ Headache ❑ Weakness
❑ Cough ❑ Loss ofsmell/taste ❏ ❏
❑ Colds ❑ Diarrhea
❑ Sorethroat ❑ Shortnessofbreath/difficultyin
❑ Myalgia breathing
❑ Rashes

HashistoryofexposuretoaconfirmedorsuspectedCOVID-19caseinthepast2 weeks? ❏ ❏

Has been previously treated for COVID-19 in the past 90 days? ❏ ❏

Hasreceivedanyvaccineinthepast14daysorplanstoreceiveanothervaccine14 days ❏ ❏
followingvaccination?

Has received convalescent plasma or monoclonal antibodies for COVID-19 in the ❏ ❏

past 90 days?

Pregnant? ❏ ❏

➢ Ifpregnant,areyouinthe1sttrimester? ❑ ❑

Has any of the following diseases or health condition?

❑ HIV
❑ Cancer/Malignancy
❑ UnderwentTransplant ❏ ❏
❑ Under Steroid Medication/Treatment
❑ Bedridden,terminalillness,lessthan6monthsprognosis
❑ Autoimmunedisease

Ifwithanyoftheabovementionedcondition,isthereanyobjectiontovaccination ❑ ❑
frompresentedmedicalclearancepriortovaccinationday?

Recipient’s Name:RONA ALINE D. SENTE VACCINATE

Birthdate:MAY 17, 1994 Sex:FEMALE If any of the non-gray
responses is checked, defer
vaccination
Signature of Health Worker: