ANNEX B
ANNEX B
MEDICAL HISTORY – FOR VACCINATIONS OF COVID-19
NAME OF VACCINE CENTRE
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ADDRESS OF VACCINE CENTRE
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DEMOGRAPHIC INFORMATION
NAME AND SURNAME AMKA
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(completed by the vaccinated-
Authorized by the secretary CONTACT DETAILS
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HISTORY OF PREVIOUS DISEASE COVID-19
( symptomatic or not ) *
Completed by the vaccinated
While waiting HISTORY OF CONFIRMED COVID-19
YES NO If yes when
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PERSONAL MEDICAL HISTORY
*
(The categories mentioned do not
necessarily constitute a
contraindication to vaccination)
completed by the vaccinated
while waiting, authorized by
the doctor.
YES NO DON’T KNOW
Do you feel unwell today?
Have you been diagnosed with chronic heart,
lung kidney problems or metabolic disease
e.g:- diabetes, asthma, hematological problems,
disorders, asplenia, immunodeficiency,
transplants or you have been treated with immunodeficiency
medication.
If yes please write the medication and illness accordingly.
Are you on long-term treatment with anticoagulants and aspirin
Have you been vaccinated within the last two weeks
Have you shown any signs in the past episode of severe anaphylaxis,
which required treatment with injectable medication (adrenaline, cortisone) or
hospitalization?
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CONTRAINDICATIONS PRECAUTIONS.
(to be completed by the doctor. In case
vaccination is prohibited
Did you have a serious reaction to the previous vaccination of Covid-19
Are you pregnant or breastfeeding
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DOCTOR’S SIGNATURE
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For the Greek pdf form please down load here →vaccination form covid19