Quick Health Assessment Form for MR Vaccine

(Recording Form for 9 to 59 months old)

Name of the Child Date of Birth (mm/dd/yyyy)
Surname: First Name: Middle Name: / /
Suffix:
Address Age Sex
Province: City/Municipality:

Barangay: Purok/Sitio/House Number:

Contact Number (optional): Name of Barangay Health Center:

Refusal for MR (/): Indicate reason for refusal (place code):

QUICK HEALTH ASSESSMENT

Mark all appropriate spaces/boxes with a check (√)
Questions Yes No Decision Remarks
If Yes, DEFER vaccination;
1. Does the child have fever (≥37.6 refer for medical Temp:
℃ ¿? management; and set a define _____
date for the vaccination
2. Did the child receive any Measles If Yes, DEFER vaccination;
Containing Vaccine/BCG vaccine and set a define date for the
within the past 4 weeks? vaccination
If Yes, DEFER vaccination;
3. Does the child have severe illness refer for medical
and not feeling well? management; and set a define
date for the vaccination
4. Severe allergy to measles If yes, DO NOT GIVE
containing vaccine? MCV
Specify all known allergies:

5. Does the child have any of the If yes, DO NOT GIVE

following conditions: MCV
Primary immune – deficiency disease
Suppressed immune response from
medications
Leukemia
Lymphoma
Other generalized malignancy
Deferral for MR(/): Schedule of Next Visit (mm/dd/yyyy):
Indicate reason for deferral (place code):
Note:
 Malnutrition, low-grade fever, mild respiratory infections, diarrhea and other minor illnesses
should not be contraindication.

Immunization Card/Mother Baby Book available? Yes No

Assessed by: Confirmed and approved for vaccination:

Signature over printed name of the health Signature over printed name of the
worker/screener Parent/Guardian
Date (mm/dd/yyyy): Date (mm/dd/yyyy):
Given MR? Yes No
Given OPV? Yes No; Deferral (/)__ Refusal (/)___
Reason (place code): ____

Given Vitamin A? Yes; 100,000 IU (/)___ 200,000 IU (/)___

(9 to 11months: 100,000 IU; 12 to 59months: 200,000 IU) No