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CO s6 TEEM CHUNG CONG HOA XA HOI CHU NGHIA VIET NAM. pi gc lap - Ty do - Hanh phic paiéu SANG re TRUGC TIEM CHUNG VAC XIN COVID-19 Ho VA tOn esse an Namo Na —— Ngiy sinh: Nghé nghiép:..... Don vi cng téc: . Matigm ohting .. Dia chi lign he: ...... Sé dign thoai Tied sea 1. Sang lee cb 1.Tidn sir phn vé 49 2 ta len (Néu £6, log the nbn dj tng, oO 2. Tién sir bj COVID-19 trong vong 6 thang 0 o 3. Tign sit tim vie xin khée trong vong 14 ngay qua (Néu cé, logi vie xin. »}| 0 a 4,7Tidn sir enh man tinh dang tin trién (Neu €6, loi ben a a) a 45.Dang bi suy gidm khi nang éép tmg mi&n dich mang, ung thy giai doan cubi, da cit ach, dang ding thube te 0 Oo ché mién dich, corticoid liéu cao (tuong duong hodc hon 2 mg prednisolone/kg/ngéy trong it nhét 7 ngay) 6.Bénh dp tinh (Néu 66, loa’ bénh mic... ao a 7.-Dang mang thai, phy ni dang cho con bi bing sta me ao a 8.Tidn ait dj img voi bit ky dj nguyén nto oO a 9. Tién sir ah nén, bah man tinh duge diéu tr &n dinh (Néu c6, logi bénh: ao a 10, Tin sirréi logn déng mawedim méu ho¥e dang ding thube chéng dng o a 1. DG mudi 2 65 tudi o o 12, Bat théromg ddu higu sing (ehir5) a o Nhigt gf yh c Mich: iniphit Huyét ap: 1 mmtig Nhip the: linfphit Sp: %(obucd) 13. Déu higu bét thutmg khi nghe tim phdi Qo a 14, Réi loan tri gide a a 15. Ba tiém mai 1 vie xin phong COVID-19: D Chvatiém D_ Ba tiém, logi vie xin 1. Két tun Thi Bia. Bienen phi, « Di didu kin tiém ching ngay a BAY. nothdN. ene 2021 (1étcd dé KHONG o6 diém ii thudng) ees + Chéng chi dink tiém vic xin cing logi o (kf, ghirb hp va tea) (Khi CO didm bdt teéng tai cdc muc 1) F «Trihoin tiém ching 0 (Khi CO bat ky mou did bdt taeomg tai ede muc 2, 3, 4,5. 6,7) * Chuyén tim ching va theo doi tai benk vign Qo (Khi CO tai céic muc 8, 9,10, 11, 12) Dé nghj chuyén dén Ly de: - © Thoi giam tim: esses Yoeoos oe POE MBAY. sof2021 phat IIL Tham khsim sau tiem 2 30 phat Neiy:. in erat Tai vj tritiém: ..... soe eenneean a duge huréng din theo doi sau tim, Neubi Téng trang: . lies isa nats OGY

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