中华人民共和国出入境检验检疫

黄热病疫苗接种申请表

APPLICATION FORM FOR VACCINATION AGAINST YELLOW FEVER

 

编号        

申请人姓名                                  性别     □男      □女

Applicant’s name                             Sex       Male      Female

出生日期              国籍                  前往国家/地区

Birth date             Nationality             Country/region plan to visit                   _

若带有免疫接种记录，请出示。

(Please show the vaccination record if you bring it with you.)

 

请仔细阅读下列内容,确定有无接种禁忌症和慎用症。如有接种禁忌症和慎用症，请在相应的□内打“√”标记。若有隐瞒，责任自负。(Read the following to make sure if you have any contraindication and precautions to vaccination. If you have contraindications and precautions, please check the corresponding boxes. You should be responsible for any concealment of the fact.)

黄热病疫苗预防接种禁忌症和慎用症包括（Contraindications and precautions to vaccination against yellow fever include）:

1. □ 发热（fever）                             2.□ 急性疾病（Acute illnesses）

3. □ 严重心、肝、肾等慢性病（Severe chronic illnesses, such as heart ,liver or kidney disease）

4. □ 有过敏史,尤其对鸡蛋过敏者（History of allergy, especially allergy to eggs）

5. □ 怀孕(Pregnancy)                          6.□ 哺乳期（Nursing mother）

7. □ 小于9月龄的婴儿（Infant aged < 9 months）  8.□65岁以上老人（Person aged > 65 years）

9. □ 结核病（TB）    10.□ 糖尿病(Diabetes)   11.□ 高血压病(Hypertension)

12.□ 近期使用过免疫球蛋白(Recent receipt of Immune globulin)

13.□ 肿瘤、艾滋病及其他免疫功能低下疾病(Cancer, AIDS or any other Immunodeficiency)

14.□ 正在使用激素类药物或进行抗肿瘤化疗、放疗(Receiving treatment with cortisone, prednisone steroids, anticancer drugs or radiation therapy)

15.□ 其它严重疾病或情况,请说明。(Other severe diseases or conditions，please describe in detail):

                                                                                          

 

声   明 Statement

本人有相应的黄热病疫苗预防接种禁忌症和慎用症，特此声明。

I hereby make the declaration that the applicant has corresponding contraindications and precautions to vaccination against yellow fever.

申请人、监护人或代理人签名                             申请日期

Applicant, guardian or agent signature                     Application date              

联系地址                                               电话：

Contact  address                                        Tel:                         

 

声   明Statement

本人无任何的黄热病疫苗预防接种禁忌症和慎用症，特此声明。

I hereby make the declaration that the applicant hasn’t any contraindications and precautions to vaccination against yellow fever.

申请人、监护人或代理人签名                             申请日期

Applicant, guardian or agent signature                     Application date             

联系地址                                               电话：

Contact  address                                        Tel: