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Immunization Screening Questionnaire

To ensure a safe vaccination, please read the following questions carefully and complete the form by selecting the appropriate response as either the Patient, Parent, or Legal Guardian.
(* indicates a required field. Either a cell phone number or a landline number must be provided.)
This form is valid only on the day it is completed.

Immunization Screening Questionnaire form

Immunization Screening Questionnaire form
Personal Information of Vaccine Recipient
*Name		Newborn status	New born recipient
*Resident Registration Numbers (Foreign Registration Number)	-
Cell Phone		Telephone
*Sex		Weight	kg
*Date of Birth(YYYY.MM.DD)	년 월 일

Immunization Screening Questionnaire form
*Consent for Collection and Use of Personal Information	Identity Verification ☑
In accordance with Article 32 of the Infectious Disease Control and Prevention Act and Article 32-3 of its Enforcement Decree, we collect personal and sensitive information, including your Resdent Registration Number. The details of the collection and use are as follows: Purpose of Collection and Use: To provide notifications regarding upcoming vaccinations and completion status / To monitor adverse events following immunization (AEFI) through SMS and mobile applications Collected Information: Personal data (including sensitive information and Resident Registration Number) / Home and mobile phone numbers Retention period: 5 years
I hereby consent to the verification of my (or my child’s) vaccination records through the Immunization Registry Information System (IRIS) under Article 26-2 of the Infectious Disease Control and Prevention Act. If you do not consent, healthcare providers may request your vaccination history in writing, and you must comply unless there are special circumstances.	Yes No
I agree to receive SMS and mobile app notifications regarding upcoming vaccinations and completion status. If you do not consent, you will not receive updates on vaccination schedule updates.	Yes No
I agree to receive SMS and mobile app notifications regarding the monitoring of adverse events following immunization (AEFI). for monitoring adverse events following immunization (AEFI). If you do not consent, you will not receive notifications related to AEFI monitoring.	Yes No
*Pre-Immunization Screening Checklist (To be completed by the Patient, Parent, or Legal Guardian)	Identity Verification ☑
Have you received any vaccinations in the past month? If yes, please specify the vaccine.	Yes No
Have you ever experienced adverse reactions following a vaccination that required medical treatment? If yes, please specify the vaccine.	Yes No
Are you feeling unwell today? If yes, please describe your symptoms.	Yes No
(For female recipients only) Are you currently pregnant or planning to become pregnant within the next month?	Yes No
Have you ever had an allergic reaction (such as hives, rash, anaphylactic shock, breathing difficulties, loss of consciousness, or swelling of the lips/month) to medications, food (e.g., eggs), or vaccines?	Yes No
Have you ever been diagnosed with cancer, leukemia, or an immune system disorder? If yes, please specify.	Yes No
In the past therr months, have you received steroids, chemotherapy, or radiation therapy?	Yes No
In the past year, have you received a blood transfusion or immunoglobulin treatment?	Yes No
(For COVID-19 vaccination) Do you have a blood clotting disorder or are you currently taking anticoagulants? If yes, please specify the condition or medication.	Yes No
Have you ever experienced seizures or neurological conditions (e.g., Guillain-Barré Syndrome)?	Yes No
Have you ever been diagnosed with or treatd for ay congenital anomalies, asthma, lung disease, cardiovascular disease, kidney disease, liver disease, endocrine disorders (e.g., diabetes), or blood disorders (excluding blood clotting disorders)? If yes, please specify.	Yes No

Immunization Screening Questionnaire form
*Acknowledgement & Consent for Vaccination I confirm that I have received an explanation regarding my (or my child’s) medical examination and potential adverse events following immunization (AEFI). I consent to the administration of the vaccination.	Patient or Parent/ Legal Guardian
Relationship to Vaccine recipient
Guardian's name
National Registration Number of legal guardian	-

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