Name:

Company: (Please specify company)

Employee Number: (indicated on your ID)
Age:
Home Address:
Position/Designation:
Branch:
Height:
Weight:
Gender:
If female: Pregnant?
Breastfeeding?

Medical History:

1. Do you have Allergies?

a. If yes, please specify:
2. Any severe allergic reaction associated with a vaccine?
3. With Comorbidities?
If yes, please select below:
a. Chronic pulmonary disease (COPD)
b. Hypertension
c. Cardiovascular disease
d. Chronic kidney disease
e. Cerebrovascular disease
f. Malignancy or cancer
g. Diabetes
h. Obesity
i. Chronic liver disease
j. Neurologic disease
k. Immunodeficiency state
l. Others: ___________________________
4. (Yes or no)
a. Chronic smoking?
b. History of drug abuse?
c. Tuberculosis first two (2) months treatment
d. Recent major surgery, within one (1) year
e. On maintenance drugs?
If yes, please specify what? ___________
f. Received any vaccine aside from COVID 19 vaccine?
If yes, please specify ______________
5. History of COVID-19 Infection (+ RT-PRC Test)?
If yes, please specify when? ___________
6. Exposed to COVID-19 patient?
7. Willing to be vaccinated?