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?