Annex D Quick Health Assessment Form - MR Vaccine
Annex D Quick Health Assessment Form - MR Vaccine
Barangay: City:
Note: Malnutrition, low-grade fever, mild respiratory infections, diarrhea and other minor illnesses should not be a
contraindication.
Signature over printed name of the health Signature over printed name of the
worker/screener Parent/Guardian
Date (mm/dd/yyyy): Date (mm/dd/yyyy):