Chung Cheng University Measles, Mumps, Rubella (MMR) Vaccination Consent Form. Name: Student No.: Dept./Institute/Class: Date of Birth: / / (DD/MM/YYY

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1 麻疹德國麻疹及腮腺炎三合一疫苗接種評估單及同意書基本資料姓名 :, 學號 :, 系所 : 出生日期 : 公元年月日, 聯絡電話 : 健康評估評估內容 1. 以前預防接種後是否有嚴重特殊反應, 如發高燒 (40.5 以上 ) 抽痙昏迷休克等 2. 是否曾對同一類疫苗或對疫苗的任何成分 ( 如雞蛋明膠及新黴素 ) 有過敏反應 3. 是否有嚴重心臟肝臟腎臟白血病癌症等病史 4. 一年內有否抽痙狀況 5. 現在身體有無任何病徵, 如發燒 (38.5 以上 ) 嘔吐呼吸困難等或正服用八寶粉驚風散水楊酸 ( 阿斯匹靈 ) 等藥物及最近三天內有無就醫吃藥等情形 6. 最近三個月曾否肌肉注射免疫球蛋白 ( 免疫血清 ) 或免疫抑制劑最近六個月是否曾輸過血或接受靜脈注射血液製品最近十一個月內是否曾靜脈注射高劑量免疫球蛋白請勾選有或無有無麻疹 - 腮腺炎 - 德國麻疹疫苗 MMR 如何注射用來預防麻疹腮腺炎德國麻疹為活性減毒疫苗, 一般成人使用皮下注射一劑, 對三種疾病的預防效果可達 95% 以上, 並可獲長期免疫接種的注意事項 : 1. 接種三個月內應避免懷孕 2. 如曾注射過免疫球蛋白血漿或輸血, 則要等三個月後才能接種, 以免失效何種情況不適合注射 1. 患有嚴重疾病者, 但一般感冒仍可接受注射 2. 免疫不全者, 如使用腎上腺皮質素或抗癌藥物者 3. 懷孕婦女會產生之副作用 1. 局部反應很少 2. 與麻疹疫苗一樣在接種後第五至十二天, 偶有疹子咳嗽鼻炎或發燒 3. 與德國麻疹疫苗一樣, 偶有發燒暫時性關節痛 4. 腮腺炎疫苗曾有引起輕微中樞神經反應之病例報告, 但機率極小同意接種請簽名 : ( 未滿 20 歲者應由法定代理人或家長簽名 ) 簽名日期 : 公元年月日

2 Chung Cheng University Measles, Mumps, Rubella (MMR) Vaccination Consent Form. Name: Student No.: Dept./Institute/Class: Date of Birth: / / (DD/MM/YYYY) 1. Do you have any illness or condition that increases their risk of bleeding? Yes No 2. Have you ever had a severe reaction to any medication or vaccine (including anaphylaxis)? Yes No 3. Have you had any serious illness? Yes No 4. Are you currently taking medication? (Include ointments/creams that affect the immune system e.g. Protopic cream) Yes No 5. Have you had any vaccines in the past 3 months? Yes No Signature: ( Under age of 20, please sign by the legal representative) Date: / / (DD/MM/YYYY)

3 MMR Vaccine (Measles, Mumps and Rubella): What you need to know 1. Why get vaccinated? Measles, mumps, and rubella are serious diseases. Before vaccines they were very common, especially among children. Measles Measles virus causes rash, cough, runny nose, eye irritation, and fever. It can lead to ear infection, pneumonia, seizures (jerking and staring), brain damage, and death. Mumps Mumps virus causes fever, headache, muscle pain, loss of appetite, and swollen glands. It can lead to deafness, meningitis (infection of the brain and spinal cord covering), painful swelling of the testicles or ovaries, and rarely sterility. Rubella (German Measles) Rubella virus causes rash, arthritis (mostly in women), and mild fever. If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects. These diseases spread from person to person through the air. You can easily catch them by being around someone who is already infected. Measles, mumps, and rubella (MMR) vaccine can protect children (and adults) from all three of these diseases. Thanks to successful vaccination programs these diseases are much less common in the U.S. than they used to be. But if we stopped vaccinating they would return. 2. Who should get MMR vaccine and when? Children should get 2 doses of MMR vaccine: First Dose: months of age Second Dose: 4 6 years of age (may be given earlier, if at least 28 days after the 1st dose) Some infants younger than 12 months should get a dose of MMR if they are traveling out of the country. (This dose will not count toward their routine series.)

4 Some adults should also get MMR vaccine: Generally, anyone 18 years of age or older who was born after 1956 should get at least one dose of MMR vaccine, unless they can show that they have either been vaccinated or had all three diseases. MMR vaccine may be given at the same time as other vaccines. Children between 1 and 12 years of age can get a combination vaccine called MMRV, which contains both MMR and varicella (chickenpox) vaccines. There is a separate Vaccine Information Statement for MMRV. 3. Some people should not get MMR vaccine or should wait. Anyone who has ever had a life-threatening allergic reaction to the antibiotic neomycin, or any other component of MMR vaccine, should not get the vaccine. Tell your doctor if you have any severe allergies. Anyone who had a life-threatening allergic reaction to a previous dose of MMR or MMRV vaccine should not get another dose. Some people who are sick at the time the shot is scheduled may be advised to wait until they recover before getting MMR vaccine. Pregnant women should not get MMR vaccine. Pregnant women who need the vaccine should wait until after giving birth. Women should avoid getting pregnant for 4 weeks after vaccination with MMR vaccine. Tell your doctor if the person getting the vaccine: - Has HIV/AIDS, or another disease that affects the immune system - Is being treated with drugs that affect the immune system, such as steroids - Has any kind of cancer - Is being treated for cancer with radiation or drugs - Has ever had a low platelet count (a blood disorder) - Has gotten another vaccine within the past 4 weeks - Has recently had a transfusion or received other blood products Any of these might be a reason to not get the vaccine, or delay vaccination until later. 4. What are the risks from MMR vaccine? A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions.

5 The risk of MMR vaccine causing serious harm, or death, is extremely small. Getting MMR vaccine is much safer than getting measles, mumps or rubella. Most people who get MMR vaccine do not have any serious problems with it. Mild problems Fever (up to 1 person out of 6) Mild rash (about 1 person out of 20) Swelling of glands in the cheeks or neck (about 1 person out of 75) If these problems occur, it is usually within 6-14 days after the shot. They occur less often after the second dose. Moderate problems Seizure (jerking or staring) caused by fever (about 1 out of 3,000 doses) Temporary pain and stiffness in the joints, mostly in teenage or adult women (up to 1 out of 4) Temporary low platelet count, which can cause a bleeding disorder (about 1 out of 30,000 doses) Severe problems (very rare) Serious allergic reaction (less than 1 out of a million doses) Several other severe problems have been reported after a child gets MMR vaccine, including: - Deafness - Long-term seizures, coma, or lowered consciousness - Permanent brain damage These are so rare that it is hard to tell whether they are caused by the vaccine. 5. What if there is a serious reaction? What should I look for? Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination.

Pneumonia - Traditional Chinese

Pneumonia - Traditional Chinese Pneumonia When you have pneumonia, the air sacs in the lungs fill with infection or mucus. Pneumonia is caused by a bacteria, virus or chemical. It is not often passed from one person to another. Signs