FOREST LAKE LOCAL DOCTORS – Camira, Springfield
Bookings (07)2111-9111 | FAX (07)2111-9100, 2 Rawle St, Camira QLD 4300 | Open 6 days
Please enable JavaScript in your browser to complete this form.Name of person completing this form: *FirstMiddleLastPlease fill in the following questionnaire. *FirstLastPatient’s name.Date of birth:Age today (for example, 2 weeks old or 4 years old etc)Is unwell today?YESNONOT SUREThe patient who gets vaccination.has a disease that lowers immunity (e.g. leukaemia, cancer, HIV/AIDS) or is having treatment that lowers immunity (e.g. oral steroid medicines such as cortisone and prednisone, radiotherapy, chemotherapy) ?YESNONOT SUREis an infant of a mother who was receiving highly immunosuppressive therapy (e.g. biological disease modifying anti-rheumatic drugs (bDMARDs) during pregnancy ?YESNONOT SUREhas had a severe reaction following any vaccine ?YESNONOT SUREhas any severe allergies (to anything) ?YESNONOT SUREhas had any vaccine in the past month ?YESNONOT SUREhas had an injection of immunoglobulin, or received any blood products or a whole blood transfusion within the past year ?YESNONOT SUREis pregnant ?YESNONOT SUREhas a past history of Guillain-Barré syndrome ?YESNONOT SUREwas a preterm infant ?YESNONOT SUREhas a chronic illness ?YESNONOT SUREidentifies as an Aboriginal or Torres Strait Islander ?YESNONOT SUREdoes not have a functioning spleen ?YESNONOT SUREis planning a pregnancy or anticipating parenthood ?YESNONOT SUREis a parent, grandparent or carer of a newborn ?YESNONOT SURESubmit