Vaccination sheet- multiple vaccination
Date
Information about the employee
Last name, first name _____________________________________________________________
Date of birth ____________ health insurance _________________________________
Address* ______________________________________________________________
Telephone / Mobil * ______________________________________________________________
Information about the employer
Name ______________________________________________________________
Address ______________________________________________________________
*Note: You can choose how you want to be reachable, if necessary (privat or business)
The following ticked vaccinations are planned:
О Cholera (О oral-/ О needle – vaccination) О Meningococcal Meningitis (О ACWY/ О B / О C)
О FSME (tick-borne encephalitis) О Pneumococcal (О conjugate / О polysaccharide)
О Yellow fever О Poliomyelitis
О Hepatitis A О Tetanus and or Diphtheria
О Hepatitis B О Tetanus – Diphtheria – Pertussis combination
О Hepatitis A/B – combination О Tetanus – Diphtheria – Polio – combination.
О Hepatitis A – Typhoid – combination О Tetanus – Diphtheria – Pertussis – Polio
О HPV (human Papillomavirus) О Rabies
О Influenza О Typhus (О oral-/ О needle – vaccination)
О Japanese Encephalitis О Varicella
О Measles / Mumps/ German Measles О Zoster
О Measles / Mumps / German Measles / Varicella
For this, you are kindly asked to carefully read the special information sheets on the individual vaccinations,
which we have given you with this questionnaire, to answer the following questions and to document your
consent on the back. In addition, we ask you to answer any questions you may have on our travel question-
naire after vaccinations have already taken place.
Questions Yes No
Have you had any health problems, especially allergic reactions (rashes, shortness of breath, О О
welling of the face or tongue), during or after previous vaccinations?
Are you known to have allergies, especially to vaccine ingredients such as egg white, antibi- О О
otics (especially gentamicin, neomycin), formaldehyde (formalin), latex, Thiomersal (mer-
cury)? If yes, which ones?
Do you have any health problems now? О О
Are you suffering from severe chronic diseases, especially seizures (e.g. epilepsy) or damage О О
to the nervous system (e.g. MS)?
Are you scheduled for surgery in the next two weeks? О О
Do you have a disease of the immune system? Do you take or have you taken any medica- О О
tion in the last 3 months that suppress your immune system, eg. cortisone?
Are you doing a hypersensitization right now? О О
(There should be 1 to 2 weeks between vaccination and hypersensitization injection.)
Do you suffer from a blood clotting disorder? Do you take anticoagulants? О О
Have you received immunoglobins or a blood transfusion in the last 3 months? О О
(Live vaccines can be neutralized in this way)
Have you been / will you be vaccinated in the last/ next 4 weeks? If yes, against what? О О
Only women: Are you pregnant? Are you planning a pregnancy? Do you breastfeed? О О
Bitte fragen Sie uns, wenn Sie etwas nicht verstehen oder weitere Fragen haben.
Please ask us if you do not understand something or have further questions
Bitte bringen Sie zu allen Impfungen Ihren Impfausweis mit!
Letter of agreement
I have taken note of the contents of the marked leaflets and have been advised by the vaccinator on the vac-
cinations. If necessary, I have clarified further questions with the vaccinator.
О I have no further questions and would like to be vaccinated accordingly.
О I reject all / the following vaccination(s): ___________________________________________
О I was informed about possible disadvantages of the refusal of this vaccination(s).
_____________________________________________________________________
Date, signature (for minors under the age of 16, the parent or legal guardian)
Due to the very rare allergic reactions, it is recommended to remain in the vaccination zone or under medical
supervision for 15 - 20min after vaccination.
Vaccination documentation
Vaccination against: Injection into upper arm
Date Vaccine Batch number Vaccinator ri le sc im
Dosage 1
Dosage 2
Dosage 3
Vaccination against: Injection into upper arm
Date Vaccine Batch number Vaccinator ri le sc im
Dosage 1
Dosage 2
Dosage 3
Vaccination against: Injection into upper arm
Date Vaccine Batch number Vaccinator ri le sc im
Dosage 1
Dosage 2
Dosage 3
Vaccination against: Injection into upper arm
Date Vaccine Batch number Vaccinator ri le sc im
Dosage 1
Vaccination against: Injection into upper arm
Date Vaccine Batch number Vaccinator ri le sc im
Dosage 1
Questions before 2nd / 3rd dose (to be clarified by vaccinator, if necessary do not vaccinate or vaccinate later) Can you stand the
vaccination? Relevant changes regarding diseases / allergies. Surgery? Pregnancy? Immunosuppression? Acute diseases?
_________________________________________________
Signature/ abbreviation of the doctor providing information:
