NAME OF PATIENT (LAST, FIRST, MI)
BIRTHDATE
SEX
RACE
COUNTY OF RESIDENCE
CLINIC CODE
ALLERGIES:
INSURANCE STATUS ■ IP (Insurance pays for shots)
SOCIAL SECURITY NUMBER
DOES PATIENT HAVE MEDICAID NUMBER? ■ Yes, enter number ■ No Home:
ADDRESS (Include City, Street, Zip) ■ IDP (Insurance doesn’t pay for shots or if unknown) NAME OF PARENT, GUARDIAN, RESPONSIBLE ADULT
TELEPHONE NUMBERS Work: Message:
■ IN
(No Insurance)
VACCINE* DTP/Hib DTP/Hib DTP/Hib DTP/Hib DTP/Hib
DTP DT DTP DT DTP DT DTP DT DTP DT DTaP Td DTaP Td DTaP Td DTaP Td DTaP Td
AGE
VIS** TITLE / DATE
DATE VACCINE GIVEN
DOSAGE / ROUTE / SITE
MFG. AND LOT NUMBER
VACCINE* Hep A Hep A Hep B Hep B Hep B Hep B PCV PCV PCV PPV PPV PPV Rotavirus Rotavirus Rotavirus In uenza In uenza In uenza MCV4 MCV4 Other
AGE
VIS** TITLE / DATE
DATE VACCINE GIVEN
DOSAGE / ROUTE / SITE
MFG. AND LOT NUMBER
CIRCLE ONE
OPV / EIPV OPV / EIPV OPV / EIPV OPV / EIPV OPV / EIPV MMR MMR Hib Hib Hib Hib Varicella Varicella HPV HPV HPV
TB SKIN TEST (PPD) DATE
CHECK (✔) NURSE PPD RESULTS (mm)
LEAD / HEMATOCRIT NURSE DATE
TEST NURSE LEAD HCT
RESULTS
NURSE
QP2-WC.CHART,1-2/09
* Document dates of previous vaccines based on proper veri cation. ** Document titles and date of Vaccine Information Statement (VIS).