Health questionnaire

This questionnaire asks questions about your health at the moment. We use the questionnaire to decide, for example, if you can get the coronavirus vaccination on the day of your appointment. Or if there is anything special we need to know when we give the vaccination. In certain situations, it is better to get the coronavirus vaccination some other time. That is why the GGD does one last check before you get the vaccination.

  • Fill in this questionnaire.
  • On the day of your appointment, check if you need to change any of the answers.  
  • Take the completed questionnaire with you to your vaccination appointment.

On this page you can find the questionnaire about your health in different languages for everyone aged 12 or over. And the questionnaire for children aged 0.5 to 11.  

Can you not open the questionnaire? Or are you getting an error message? Below we explain how you can open it in a different way. Can you not print the questionnaire? You can also fill in a questionnaire at the vaccination centre. 

English

This questionnaire asks questions about your health. Print the questionnaire at home and fill it in. Take the completed questionnaire with you to your vaccination appointment.

Nederlands

In deze vragenlijst staan vragen over jouw gezondheid. Print thuis de vragenlijst en vul hem in. Neem de ingevulde vragenlijst mee naar je prikafspraak.

عربية

يحتوي هذا الاستبيان على أسئلة حول صحتك
ل. قم بملء هذا الاستبيان بالم ن ز
خذ الاستبيان المكتمل معك عندما تذهب لموعد اللقاح

українська мова

Ця анкета містить питання щодо Вашого здоров’я. Заповніть цю анкету вдома. Візьміть заповнену анкету із собою, коли підете на вакцинацію.

Język polski 

Niniejszy kwestionariusz zawiera pytania dotyczące Pana(-i) stanu zdrowia. Kwestionariusz należy wypełnić w domu. Proszę mieć kwestionariusz przy sobie w chwili szczepienia.

Türkçe

Bu soru listesinde sağlığınızla ilgili sorular bulunmaktadır. Soruları evinizde cevaplayıp gelin. Cevapladığınız soru listesini aşı randevunuza gelirken yanınızda getirin.

ትግሪኛ

እዚ ናይ ሕቶታት ዝርዝር ብዛዕባ ጥዕናኻም ዝምልከቱ ሕቶታት ዝሓዘ እዩ። ነዞም ሕቶታት እዚኣቶም ኣብ ቤትኩም ኮይንኩም ኢኹም ትምልስዎም። ነዞም ሕቶታት ምስ መለስኩሞም ናብ ናይ ክትባት ቈጸራኹም ምሳኹም ሒዝክሞም ምጹ።

English

This questionnaire asks questions about the health of your child. Print the questionnaire at home and fill it in. Take the completed questionnaire with you to the vaccination appointment.

Nederlands

In deze vragenlijst staan vragen over de gezondheid van jouw kind. Print thuis de vragenlijst en vul hem in. Neem de ingevulde vragenlijst mee naar de prikafspraak.

Can you not open the questionnaire? Or are you getting an error message?

Then open it in a different way. You can do this in three steps: 

  1. Copy the Internet address of the questionnaire in the bar at the top of this screen: https://ggdafspraak.nl/en/coronavirus/health-questionnaire/
  1. Open a private window in your Internet program. How you do this depends on your Internet program: 
    Edge and Chrome: Click on the icon with the three dots in the top right corner. And then click on ‘New Private window’ or ‘New incognito window’. 
    Firefox: Click on the icon with the three dashes in the top right corner. And then click on ‘New Private Window’. 
    Safari: Click on ‘Archive’ in the menu bar. And then click on ‘New private window’. 
  1. Paste the Internet address of this page in the bar at the top of the private window. This screen will now open again. Then click on the health questionnaire you are looking for.