Vragenlijst

Vragenlijst (anamnese)

Complete your questionnaire (medical history) digitally, print it off and take it with you to the vaccination centre.
(This information will NOT be stored in an electronic database)

I provide consent for vaccination

1. Have you ever had a serious allergic reaction?

Yes

2. Are you currently pregnant?

Yes

3. Have you tested positive for the coronavirus within the past 14 days?

Yes

4. Have you recovered from a coronavirus infection within the past 14 days?

Yes

5. Do you suffer an illness, or take medication, that compromises your immunity?

Yes

6. Have you had glands removed from your armpit?

Yes

7. Do you take blood thinning medication?

Yes

8. Do you take any other medication on a daily basis?

Yes

9. Do you suffer from one of the following conditions?

Epilepsy

Diabetes

Blood pressure issues (e.g. high blood pressure, low blood pressure, fluctuating blood pressure)

Heart rhythm problems (e.g. fast pulse, slow pulse, irregular pulse)

Asthma