Hi, I need 2 minutes of your time to take a brief Contraindications Checklist. This is part of our Client Safety Protocol. Will you do this with me?
The following questions will help us determine your safety status to be Vaccinated. If you answered YES to all these questions, it doesn't mean you should not be vaccinated. It just means additional questions must be asked. Please answer honestly.
I Will Do This With You
 
Let's start with your personal info, shall we? What's your name? *

Mari memulai dengan informasi diri anda. Siapakah nama anda?
 
Great {{answer_26514786}}, and your last name is? *

{{answer_26514786}}, nama belakang anda adalah?
 
{{answer_26514786}}, which year were you born in? *

{{answer_26514786}}, pada tahun berapakah anda lahir?
 
What about the date? *

Tanggal lahir anda adalah?
 
Your biological gender is... *

Pilih jenis kelamin biologis anda


 
Would you mind providing us with your mobile number? *

Mohon sertakan nomor handphone anda...
 
For verification purposes, please provide us your instagram username? *

Untuk keperluan verifikasi identitas, mohon sertakan username instagram anda...
 
Which city are you currently living in Indonesia? *

Di kota manakah anda tinggal di Indonesia?

 
We need your address for your intended appointment visit. Home / Office / Other preferred location. *

Mohon sertakan alamat untuk janji temu anda. Rumah / Kantor / Lokasi lainnya.
 
What vaccination do you intend of getting? *

Vaksinasi apakah yang hendak anda dapatkan?

 
Okay then {{answer_26514786}}, let's get on with the checklists, shall we?

Baiklah {{answer_26514786}}, mari kita mulai dengan ceklis keamanan vaksinasi...
 
Are you feeling sick today? *

Apakah anda merasa sakit hari ini?

 
If you answered YES, please tell me how you are feeling. If NO, click next

Apabila anda memilih YES, ceritakan keluhan anda. Apabila anda memilih NO, tekan next
 
Do you have allergies to medications, food, a vaccine component, or latex? *

Apakah anda mempunyai alergi terhadap obat-obatan, makanan, komponen vaksin, atau karet lateks?

 
Have you ever had a serious reaction after receiving a vaccination? *

Apakah pernah terjadi efek samping berat setelah anda menerima vaksinasi?

 
Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? *

Apakah anda mempunyai masalah kesehatan kronis seperti penyakit jantung, penyakit paru, asma, penyakit ginjal, penyakit metabolik (co: diabetes), anemia, atau kelainan darah lainnya?

 
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? *

Apakah anda penderita kanker, leukemia, HIV/AIDS, atau masalah sistim imun lainnya?

 
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments? *

Dalam 3 bulan terakhir, apakah anda mengkonsumsi obat-obat yang menekan sistim imun anda; seperti prednisone, steroid lainnya, obat kanker, obat untuk radang sendi rematik, penyakit Chron's, atau psoriasis? Atau apakah anda menerima terapi radiasi?

 
Have you had a seizure or a brain or other nervous system problem? *

Apakah anda pernah kejang, atau memiliki kelainan otak atau persarafan?

 
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug? *

Dalam setahun terakhir, apakah anda telah menerima transfusi darah atau produk darah, atau menerima pengobatan dengan gamma-globulin, atau obat anti virus?

 
For FEMALE: Are you pregnant or is there a chance you could become pregnant during the next month?

Khusus WANITA: Apakah anda sedang mengandung, atau adakah kemungkinan anda akan mengandung bulan depan?

 
Have you received any vaccinations in the past 4 weeks? *

Apakah anda telah menerima vaksinasi (apapun) dalam 4 minggu terakhir?

 
That's it! We're done! *

Were you having problems with the alien words? It's alright, if you're not familiar with the BIG SCARY MEDICAL words, chances are you've never had them. :)

 
We'll be in touch soon, {{answer_26514786}} . Thank you for your time :)

Kami akan menghubungi anda segera, {{answer_26514786}}. Terima kasih atas waktu dan kerjasama nya. :)
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