Medical Questionnaire

Step 1 of 2

Name
First Last
Class
Date of Birth
MM slash DD slash YYYY
Year of Entry to the School
Has your child had any vaccine against the following?
- Mumps
- Measles
- Scarlet Fever
- Rheumatic Fever
- Diphtheria
- Chicken Pox
- Whooping Cough
- Meningitis
- German measles (Rubella)
If Yes, Please Check the appropriate boxes
RECORD OF IMMUNISATIONS
BCG
MM slash DD slash YYYY
DIPTHERIA
MM slash DD slash YYYY
HEPATITIS A
MM slash DD slash YYYY
HEPATITIS B
MM slash DD slash YYYY
INFLUENZA/ FLU
MM slash DD slash YYYY
MEASLES, MUMPS AND RUBELLA (MMR)
MM slash DD slash YYYY
MENINGITIS
MM slash DD slash YYYY
PNEUMOCOCCAL INFECTION
MM slash DD slash YYYY
ROTAVIRUS
MM slash DD slash YYYY
VARICELLA(CHICKEN POX)
MM slash DD slash YYYY
VITAMIN A
MM slash DD slash YYYY
YELLOW FEVER
MM slash DD slash YYYY
OTHERS
Please, upload immunization record for reference.
Max. file size: 128 MB.