Vaccination questionnaire(英日併記予防接種予診票)

Please use the English-Japanese questionnaires below for your child when s/he gets vaccinated. Read the “Vaccination and Children’s Health 2023” (予防接種と子どもの健康 Yobo-Setsyu to Kodomono-Kenko) first before filling out the form(s).

The color of the questionnaire corresponds to each vaccination.  (Refer to the Japanese version of questionnaire booklet you received at your local health center along with the maternal and child health handbook (Boshi Techo)

Printing out and filling out the form(s) in advance will save you time at the pediatric clinics or health centers.  You can take your child’s temperature in the morning at home or at the clinic. It should be under 37.5℃.

As of February 3, 2017, Sapporo city and Sapporo Pediatric Association allow you to use these English-Japanese forms in replacement of the Japanese version provided. For routine vaccination, please use the ones with the names of each vaccination. Multi-use form is not accepted for routine vaccinations.


(Partially subsidized voluntary vaccination)

*You can use this multi-use form for voluntary vaccination such as seasonal influenza, etc.
Please do not use this form for routine vaccination such as Hib, PCV, DPT-IPV, Rotavirus, MR, chicken pox, Hepatitis B, and Japanese Encephalitis.

COVID-19 vaccination questionnaire

Translations of Prevaccination Screening Questionnaire for COVID-19 vaccine are available.

※The following is the English translation of the official form in Japanese.
 Please fill in theJapanese form by referring to the following English translation.
(The Japanese form and English translation are both  from the Ministry of Health, Labour and Welfare.)

English translation 

Instructions for COVID-19 vaccination

Manufatured by Pfizer

Manufatured by Moderna