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  • Health Assessment Form

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    Jessa Mae
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    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.

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    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    32 views2 pages

    Health Assessment Form

    Uploaded by

    Jessa Mae
    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    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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