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

1.  Children’s vaccination

Please use the English-Japanese questionnaires below for your child when s/he is going to get 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 of the available vaccinations.  (Please 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) for more information)

Printing out and filling out the form(s) in advance will save you time at the pediatric clinics or health centers.  Please take your child’s temperature in the morning at home or at the clinic. In order to get vaccinated, your child’s temperature should be under 37.5℃.

For routine vaccination, please use the forms with the names of each vaccination at the top. It is not possible to use one form for multiple vaccinations.

As of February 3, 2017, Sapporo Public Health Center and Sapporo Pediatric Association allow the English-Japanese forms to be used instead of the Japanese version for the following vaccinations.

Routine vaccinations (定期接種)


Voluntary vaccinations (任意接種)
(Partially subsidized voluntary vaccination)
→For more information on subsidy, click here.
2.  Other vaccinations (その他)
This English-Japanese medical history questionnaire can be used by both children and adults at visits for voluntary influenza vaccination. This exact questionnaire may not be accepted by all hospitals and clinics so please check with them. (This form was originally made by Iwate International Association)