Dotazník Před Očkováním COVID-19.pdf

Vaccination Questionnaire for COVID-19

- Purpose: To assess the respondent's health status, which may impact their planned COVID-19 vaccination.
- Instructions: Read each question carefully and answer truthfully. A 'Yes' answer does not necessarily mean vaccination is not possible. Consult the vaccination site doctor for clarification.
- Questions:
- Do you feel unwell at the moment?
- Have you had COVID-19 or a positive PCR test?
- Have you been vaccinated against COVID-19 before?
- Have you ever had a severe allergic reaction to a vaccine?
- Do you have any bleeding disorder or take blood-thinning medication?
- Do you have a severe immune system disorder?
- Are you pregnant or breastfeeding?
- Have you received any other vaccination in the last two weeks?
- Consent: By signing, the respondent confirms they have not withheld any health information and understands the provided information about COVID-19 vaccination, including potential side effects.
- Vaccination Agreement: The respondent agrees to the application of the COVID-19 vaccine.
- Signature: The respondent's signature and the date.
- Doctor's Information: The osetering doctor's name and signature, along with the date and a stamp.