‘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