Monday , April 12 2021

Zakynthos:- Vaccination form translated into English for Covid-19

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

About Louise Inzk

Louise is Australian born and has been a Greek citizen since 1991. She has deep cultural ties with the island, often writing about Zakynthian Traditions and Culture. She is also an active member of the Volunteer Group of Zakynthos, Giostra Di Zante and is a member of the women's choir "Rodambelos". Her love of the island and all it offers saw her joining the Zakynthos (Zante) Informer admin team in 2014.

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