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Health Assessment Form

The document is a health declaration screening form for the Philippine National COVID-19 Vaccine Deployment and Vaccination Program. It contains a list of criteria to assess if a patient can receive the COVID-19 vaccine, including questions about allergies, medical history, current symptoms, and recent exposures. If any criteria are answered "yes", the patient may need to be deferred, receive the vaccine with special precautions like observation, or get physician clearance before being vaccinated. The form also includes an algorithm to guide the assessment and vaccination process.

Uploaded by

Jessa Mae
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125 views2 pages

Health Assessment Form

The document is a health declaration screening form for the Philippine National COVID-19 Vaccine Deployment and Vaccination Program. It contains a list of criteria to assess if a patient can receive the COVID-19 vaccine, including questions about allergies, medical history, current symptoms, and recent exposures. If any criteria are answered "yes", the patient may need to be deferred, receive the vaccine with special precautions like observation, or get physician clearance before being vaccinated. The form also includes an algorithm to guide the assessment and vaccination process.

Uploaded by

Jessa Mae
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

HEALTH DECLARATION SCREENING FORM

of the Philippine National COVID-19 Vaccine Deployment and Vaccination Program

ASSESS THE PATIENT YES NO

Age more than 16 years old? ❏ ❏

Has no allergies to PEG or polysorbate? ❏ ❏

Has no severe allergic reaction after the 1st dose of the vaccine? ❏ ❏

Has no allergy to food, egg, medicines and no asthma? ❏ ❏

➢ If with allergy or asthma , will the vaccinator able to monitor the patient for 30
❑ ❑
minutes?

Has no history of bleeding disorders or currently taking anti-coagulants? ❏ ❏

➢ If with bleeding history, is a gauge 23 - 25 syringe available for injection? ❑ ❑

Does not manifest any of the following symptoms:

❑ Fever/chills ❑ Fatigue
❑ Headache ❑ Weakness
❑ Cough ❑ Loss of smell/taste ❏ ❏
❑ Colds ❑ Diarrhea
❑ Sore throat ❑ Shortness of breath/difficulty in
❑ Myalgia breathing
❑ Fatigue

Has no history of exposure to a confirmed or suspected COVID-19 case in the past 2


❏ ❏
weeks?

Has not been previously treated for COVID-19 in the past 90 days? ❏ ❏

Has not received any vaccine in the past 2 weeks? ❏ ❏

Has not received convalescent plasma or monoclonal antibodies for COVID-19 in the
❏ ❏
past 90 days?

Not Pregnant? ❏ ❏

➢ If pregnant, 2nd or 3rd Trimester? ❑ ❑

Does not have any of the following diseases or health condition?


❑ HIV
❑ Cancer/ Malignancy
❏ ❏
❑ Underwent Transplant
❑ Under Steroid Medication/ Treatment
❑ Bed ridden, terminal illness, less than 6 months prognosis

If with the abovementioned condition, has presented medical clearance prior to


❑ ❑
vaccination day?

Recipient’s Name: VACCINATE

Birthdate: Sex:

Signature of Health Worker:


HEALTH ASSESSMENT ALGORITHM
of the Philippine National COVID-19 Vaccine Deployment and Vaccination Program

ASSESS THE VACCINE RECIPIENT


Is the patient any of the following?

● Age < 16 years old YES


NO ● With allergy to PEG or polysorbate DO NOT VACCINATE
● With severe allergic reaction after the 1st dose of the
vaccine

SPECIAL PRECAUTION
YES OBSERVE FOR 30
NO With allergy to food, egg, medicine?
MINS

YES USE GAUGE 23-25.


NO Have history of bleeding disorders or currently taking
APPLY FIRM
anti-coagulants?
PRESSURE.

DEFER
Manifesting any of the following symptoms:
YES REFER TO MD.
NO RESCHEDULE
● Fever/chills, headache, cough, colds, sore throat, myalgia,
fatigue, weakness, loss of smell/taste, diarrhea, shortness of AFTER FULL
breath/difficulty in breathing RECOVERY.
VACCINATE

RESCHEDULE
NO YES
Have history of exposure to confirmed or suspected COVID-19 AFTER
case in the past 2 weeks? QUARANTINE
COMPLETION

NO YES
Have been previously treated for COVID-19 in the past 90 RESCHEDULE
days? AFTER 90 DAYS

NO YES RESCHEDULE
Have received convalescent plasma or monoclonal antibodies
for COVID-19 in the past 90 days? AFTER 90 DAYS

YES RESCHEDULE IF IN
NO Pregnant?
FIRST TRIMESTER

NO YES
Have received any vaccine in the past 2 weeks? RESCHEDULE

● With autoimmune disease?


● Diagnosed with HIV? YES
NO ● Diagnosed with Cancer/Malignancy?
GET CLEARANCE FROM
● Underwent transplant?
ATTENDING PHYSICIAN
● Under steroid treatment or medication?
● Bed ridden, terminal illness, less than 6 months
prognosis

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