(cache)Screening Questionnaire for COVID-19 vaccine

Name written on your resident card

Name(Latin character)

Katakana Name

Telephone No., divided by hyphen(-)

Date of birth

Sex

Male

Female

Q1.Are you receiving the COVID-19 vaccine for the first time?

I have never got vaccinated

I got vaccinated at least once before.

Q2.Is the city, town, or village where you currently reside the same as the city, town, or village stated on the coupon?

Yes, it's the same.

No, it's not the same city, town, or village.

Q3.Have you read the "Instructions for the COVID-19 vaccine" and do you understand the effects and adverse side effects?

Yes, and I understood.

No.

Q4.Do you fall into one of the target groups that have a higher priority for this vaccine?

Targets: Medical personnel, etc., Person 60 years or older, Worker at a senior citizen facility, etc., Person with an underlying disease

Yes, I fall into the conditions.

No.

Q5. Are you currently suffering from any kind of illness and receiving treatment or medication?

Yes, I got treated on some illness

No.

Q6. Have you had a fever or gotten sick in the last month?

Yes

Q7.Are there any parts of your body that are not feeling well today?

Yes

Q8.Have you ever had a convulsion (seizure)?

Yes

Q9.Have you ever experienced severe allergic symptoms (such as anaphylaxis) from medications or foods??

Yes

Q10.Have you ever been sick after receiving a vaccine??

Yes

Q11.Is there any possibility that you are currently pregnant (for example, your period is later than expected)? Or are you breastfeeding?

Yes

Q12.Have you had any vaccines within the last two weeks?

Yes

Q13.Do you have any questions about the vaccine today?

Yes

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