Model Standing Orders Vietnamese (PDF) by xyi12027


									    Tên bệnh nhân: ______________________                                                        Ngày sinh: ____/____/_____

                           Bảng câu hỏi kiểm tra
                Tiêm ngừa bệnh Cúm theo mùa và cúm H1N1
Đối với các bệnh nhân trưởng thành cũng như các bậc phụ huynh của các trẻ nhỏ sẽ được tiêm ngừa:
Những câu hỏi sau đây sẽ giúp chúng tôi xác định liệu có bất kỳ lý do nào mà chúng tôi không nên tiêm ngừa
bệnh cúm cho quý vị hay cho con của quý vị hôm nay không. Nếu quý vị trả lời là “có” cho bất kỳ câu hỏi nào,
điều đó không nhất thiết có nghĩa là quý vị (hay con của quý vị) sẽ không được tiêm ngừa phòng bệnh. Điều này
chỉ có nghĩa là cần phải hỏi thêm các câu hỏi. Nếu có câu hỏi nào không rõ ràng, vui lòng yêu cầu nhân viên
chăm sóc sức khỏe của quý vị giải thích câu hỏi đó.

                                                                                                       Có     Không     Biết

1. Người sẽ được tiêm ngừa bị bệnh hôm nay phải không?

2. Người sẽ được tiêm ngừa có dị ứng với trứng hay
   dị ứng với thành phần của thuốc chích ngừa khác không?

 3. Người sẽ được tiêm ngừa có bao giờ có một phản ứng nghiêm trọng với
thuốc chích ngừa (vắcxin) cúm trước đây không?

4. Người sẽ được tiêm ngừa có bao giờ mắc hội chứng Guillain-Barré không?

Biểu mẫu được hoàn tất bởi::___________________________________________ Ngày:_______________

Biểu mẫu được xét duyệt bởi:_____________________________________Ngày:_______________

                       Technical content reviewed by the Centers for Disease Control and Prevention. September 2009.

     Adapted by MDPH from Screening Questionnaire for Injectable Vaccination from the Immunization Action Coalition (9-
    Screening Questionnaire for Seasonal and H1N1 Influenza Injectable Vaccination         September 2009 (Vietnamese)
Information for Health Professionals about the Screening Questionnaire
for Seasonal and H1N1 Influenza Injectable Vaccination
Are you interested in knowing why we included a certain question on the Screening
Questionnaire? If so, read the information below. If you want to find out even more, consult the
sources listed at the bottom of this page.

1. Is the person to be vaccinated sick today?                vaccines/pubs/pinkbook/downloads/appendices/B/e
There is no evidence that acute illness reduces              xcipient-table-2.pdf.
vaccine efficacy or increases vaccine adverse
events. Persons with an acute febrile illness usually        3. Has the person to be vaccinated ever had a
should not be vaccinated until their symptoms have           serious reaction to influenza vaccine in the
improved. Minor illnesses with or without fever do           past?
not contraindicate use of influenza vaccine. Do not          Patients reporting a serious reaction to a previous
withhold vaccination if a person is taking antibiotics.      dose of inactivated influenza vaccine should be
                                                             asked to describe their symptoms. Immediate—
2. Does the person to be vaccinated have an                  presumably allergic—reactions are usually a
allergy to eggs or to a component of the                     contraindication to further vaccination against
vaccine?                                                     influenza.
Allergic reactions to any vaccine component can
occur. The majority of reactions probably are                Fever, malaise, myalgia, and other systemic
caused by residual egg protein. Although current             symptoms most often affect persons who are first-
influenza vaccines contain only a limited quantity of        time vaccinees. These mild-to-moderate local
egg protein, this protein can induce immediate               reactions are not a contraindication to future
allergic reactions among persons who have severe             vaccination. Also, red eyes or mild upper facial
egg allergy. If a person can eat eggs, they can              swelling following vaccination with inactivated
receive inactivated influenza vaccine. However,              injectable influenza vaccine is most likely a
persons who have experienced an anaphylactic                 coincidental event and not related to the vaccine;
reaction (e.g., hives, swelling of the lips or tongue,       these persons can receive injectable vaccine
acute respiratory distress, or collapse) after eating        without further evaluation.
eggs should consult a physician for appropriate
evaluation to help determine if vaccine should be            4. Has the person to be vaccinated ever had
administered. Persons who have documented                    Guillain-Barré syndrome?
immunoglobulin E (IgE)-mediated hypersensitivity             It is prudent to avoid vaccinating persons who are
to eggs, including those who have had occupational           not at high risk for severe influenza complications
asthma or other allergic responses to egg protein,           but who are known to have developed Guillain-
might also be at increased risk for allergic reactions       Barré syndrome (GBS) within 6 weeks after
to influenza vaccine. Consultation with a physician          receiving a previous influenza vaccination. As an
should be considered. Protocols have been                    alternative, physicians might consider using
published for safely administering influenza vaccine         influenza antiviral chemoprophylaxis for these
to persons with egg allergies (see source 3).                persons. Although data are limited, the established
                                                             benefits of influenza vaccination for the majority of
FluZone (sanofi pasteur) contains gelatin as a               persons who have a history of GBS, and who are at
stabilizer; therefore a history of anaphylactic              high risk for severe complications from influenza,
reaction to gelatin is a contraindication. Some              justify yearly vaccination.
inactivated influenza vaccines contain thimerosal as         ______________________
a preservative. Most persons with sensitivity to             Sources:
thimerosal, such as that found in contact lens               1. CDC. Epidemiology & Prevention of Vaccine-Preventable Diseases,
solution, do not experience reactions to thimerosal          WL Atkinson et al., editors, at pubs/pinkbook.
administered as a component of vaccines. Check               2. CDC. “General Recommendations on Immunization:
the package insert at                      Recommendations of the Advisory Committee on Immunization
                                                             Practices (ACIP)” at
packageinserts for a list of the vaccine components          3. CDC. “Prevention and Control of Influenza—Recommendations of
(i.e., excipients and culture media) used in the             ACIP” at vaccination.
production of the vaccine, or go to             4. CDC. “Use of Influenza A (H1N1) 2009 Monovalent Vaccine” at

 Adapted by MDPH from Screening Questionnaire for Injectable Vaccination from the Immunization Action Coalition (9-
Screening Questionnaire for Seasonal and H1N1 Influenza Injectable Vaccination         September 2009 (Vietnamese)

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