Informed consent form for adult pneumonia vaccination in Lishui
[Introduction to Disease]
83% ，居首位。 Pneumonia is caused by bacteria such as pneumococcus, staphylococcus, and streptococcus, but pneumonia caused by pneumococcus is the most common, reaching 83% , ranking first. Spread through the respiratory tract. Typical symptoms are sudden onset, chills, fever, chest pain, cough, and rusty sputum. In some elderly patients, chronic diseases or patients with fragile immune dysfunction, the disease is mostly critical and can be complicated by sepsis, purulent meningitis, pericarditis, empyema and toxic pneumonia.
（以接种门诊现有疫苗为准） [Vaccine introduction] ( Subject to existing vaccines in vaccination clinics)
23 价肺炎疫苗，疫苗剂量包装为 0.5ml/ 支。 At present, the adult pneumonia vaccine provided by our city is a 23- valent pneumonia vaccine, and the vaccine dose package is 0.5ml / piece. 23 价肺炎疫苗是预防肺炎球菌肺炎的有效手段 ，能对减少慢阻肺、高血压、糖尿病等慢性病急性发作有十分重要的意义。 Vaccination with 23- valent pneumonia vaccine is an effective means to prevent pneumococcal pneumonia , and it is of great significance to reduce the acute attack of chronic diseases such as chronic obstructive pulmonary disease, hypertension, and diabetes. The vaccine belongs to the second type of vaccine and is voluntarily administered by residents at their own expense .
[Target of Inoculation]
2 周岁的所有人群，特别推荐给 60 周岁以上老年人、免疫功能低下者、患有慢性疾病等高危人群。 All persons ≥ 2 years of age are particularly recommended for those over 60 years of age, those with low immune function, and those at high risk of chronic diseases.
价肺炎球菌多糖疫苗：通常接种 1 针，其余特殊免疫程序参考产品使用说明书。 23- valent pneumococcal polysaccharide vaccine: 1 vaccination is usually given . For other special immunization procedures, please refer to the product instruction manual.
Individuals may have local pain, redness, swelling, induration, or moderate to low-grade fever. They generally do not require special treatment and can relieve themselves. If necessary, they should contact the vaccination unit for symptomatic treatment.
【ban avoid disease】
People with severe acute or chronic diseases.
、发热者暂缓接种。 1. Fever suspends vaccination.
、接种后在现场留观 30 分钟后方可离开。 2. Wait 30 minutes after the inoculation before leaving.
、 疫苗的保护效果并非100%。 3. The protective effect of the vaccine is not 100%. A small number of people do not develop protection or remain ill after vaccination, which is related to factors such as the characteristics of the vaccine and the individual's physique.
23 价肺炎疫苗 。 This party has read the above informed consent and confirmed that the recipients are healthy and eligible for vaccination. They voluntarily vaccinated with 23- valent pneumonia vaccine at their own expense .
For the specific types and prices of the second-class vaccines, please refer to the vaccination clinic publicity materials.
Seed recipient signature: contact number: date: year month day
以下由接种医生填写-------------------- ---------------- The following is filled in by the vaccination doctor --------------------
接种医生签名： Vaccination site (marked √): upper left, upper right, lower left, lower right Signature of vaccination doctor: