Client Name: Address with Postal Code: Date of Departure : _____________ PHIN #: Manitoba Registration Number: Home Phone Number : Destination Countries (*in order): Date of Birth: Work or Cell Phone: ____________________________________ Gender: Email: ____________________________________ Yellow Fever Immunization History: (*check all that apply) Received previous yellow fever fractional dose/s (YF-FD) of 疫苗; Date: ____________________ Received previous full dose of yellow fever vaccine Date: ___________________ Received no prior doses of yellow fever vaccine Received another live viral vaccine within the past 4 weeks;日期:_________________ *如果自上次剂量的活病毒疫苗以来,不应给予YF疫苗。如果客户将接收活病毒疫苗(例如MMR,MMRV或Varicella),则不要在诊所进行管理,除非您在给予黄热病疫苗之前至少允许4周允许使用。在这里确定,如果需要与YF疫苗同时给予活病毒疫苗。管理:MMRMMRV MMRV VARICELLA请确保已与客户审查以下所有几点,如适用:计划当前的旅行,其中指示YF疫苗(*检查适用的框)
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