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12

ALLEGATO 2 AL MODULO DI CONSENSO

VACCINAZIONE ANTI-COVID-19

SCHEDA ANAMNESTICA Da compilare a cura del Vaccinando e da riesaminare insieme ai

Professionisti Sanitari addetti alla vaccinazione.

Nome e Cognome:

Telefono:

Anamnesi SI NO NON SO

Attualmente è malato?

Ha febbre?

Soffre di allergie al lattice, a qualche cibo, a farmaci o

ai componenti del vaccino?

Se sì, specificare:…………………….……………………

……………………………………………………………...

Ha mai avuto una reazione grave dopo aver ricevuto

un vaccino?

Soffre di malattie cardiache o polmonari, asma,

malattie renali, diabete, anemia o altre malattie del

sangue?

Si trova in una condizione di compromissione del

sistema immunitario? (Esempio: cancro, leucemia,

linfoma, HIV/AIDS, trapianto)?

Negli ultimi 3 mesi, ha assunto farmaci che

indeboliscono il sistema immunitario (esempio:

13

cortisone, prednisone o altri steroidi) o farmaci

antitumorali, oppure ha subito trattamenti con

radiazioni?

Durante lo scorso anno, ha ricevuto una trasfusione di

sangue o prodotti ematici, oppure le sono stati

somministrati immunoglobuline (gamma) o farmaci

antivirali?

Ha avuto attacchi di convulsioni o qualche problema al

cervello o al sistema nervoso?

Ha ricevuto vaccinazioni nelle ultime 4 settimane?

Se sì, quale/i? ................................................................

……………………………………………………………….

Per le donne:

- è incinta o sta pensando di rimanere incinta nel mese

successivo alla prima o alla seconda

somministrazione?

- sta allattando?

Specifichi di seguito i farmaci, ed in particolare quelli anticoagulanti, nonché gli integratori naturali, le vitamine, i minerali o eventuali medicinali alternativi che sta assumendo:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14

Anamnesi COVID-correlata SI NO NON SO

Nell'ultimo mese è stato in contatto con una Persona

contagiata da Sars-CoV2 o affetta da COVID-19?

Manifesta uno dei seguenti sintomi:

x Tosse/raffreddore/febbre/dispnea o sintomi simil-

influenzali?

x Mal di gola/perdita dell'olfatto o del gusto?

x Dolore addominale/diarrea?

x Lividi anormali o sanguinamento/arrossamento

degli occhi?

Ha fatto qualche viaggio internazionale nell'ultimo

mese?

Test COVID-19:

x Nessun test COVID-19 recente

x Test COVID-19 negativo

(Data: ______________)

x Test COVID-19 positivo

(Data: ______________)

x In attesa di test COVID-19

(Data: ______________)

Riferisca eventuali altre patologie o notizie utili sul Suo stato di salute

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________