Influenza vaccine screening form


Personal information

Please input name.
Please input surname.

Please input contact number.
Please input email format.

Have you a medical record with Bangkok Hospital Pattaya?



1. Have you had a history of allergic reaction to influenza vaccine?




2. Have you had severe allergic reaction to eggs?




3. Are you having a fever?




4. Do you have any underlying disease?




5. Are you pregnant?

 weeks