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Patient name:Date of birth:(mo.)(yr.)(day)Screening Checklist for Contraindications to
Vaccines for Children and Teens
For parents/guardians: The following questions will help us determine which vaccines
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To fill out the form for a sick child, follow these steps:
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Start by gathering all the necessary information about the child, such as their name, age, and any relevant medical history.
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This form is typically needed by parents or legal guardians of a sick child. It allows them to provide necessary information to healthcare professionals or institutions responsible for the child's care. Additionally, this form may be required by schools or childcare facilities to document and address the child's illness, especially when it affects attendance or participation in activities.
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