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‘Anexa ne 1 CChestionar tra] vaccnare adult (CHESTIONAR TRIAI VACCINARE ADULTL [ume si prenume: Data nastri Pentru pacing: in vedere ijl pentru vaceinare va rym sit dspunsurile aire jos. | - DA Nu | NUST 1 [Avtiwce problem desintateinmomenlde ta? | o |e | 0 3 | Affavut wen eo eb, senior ui in 5 ultimele 14 zile? ° ° 4__| Vasiicuaters alien av medicamens? 2 op [ Aare wonders arn dap ea at | 0 vaca? ‘vei probleme soni de ante sama Bode Ja] = 3 «| sia ol de pli ok dein ibe. anemic Saul bel singe? 6 | Daag rspans“DA" a nish anterior, | [toni bot seit’ 7 | Aalcanser ewseni,HIVTSIDN ws onsets | = = probe | Va tious cnlemicsa ali boi nog? 3 3 Trlimele an a fat moicamente care v ba 3 5 «| sistem manta, maf coro predion sx ai stoi metiamente anticancer saa stat tamnte ud? Timo na rin ansfire de singe a0 o]3 3 10 | grouse din sings vais maoglobulins ‘Guan mesicame anvil? “ - Pena fem Snief pevidi sacra gna sb simingi gwvidhin | | a ° Sirs in unatoae? Alain preen? ° e 12° | (Ati mai facut vreun vacein in ultimele 4 siptimini? 7 7 Dac "DAY, presi ca. : a = 7. [Dect “Da%peoad dada xiemartininidin | —o[ 3 LL Hine est de pete 8 deal? Completa de Data

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