Immunization record by 5K4v9Jq8


									Centre for Nursing and Health Studies

Vaccine or toxoid                    Schedule                                  Test Date
Tetanus, Diptheria, Pertussis        History of primary series and             Primary series date:
                                     Reinforcing dose (booster) every ten      Booster date:
Polio                                History of primary series                 Primary series date:
Measles, Mumps, Rubella (MMR)        1 dose for adults born in or after 1970   Primary series date:
                                     without a history of measles or those     Booster date:
                                     individuals without evidence of
                                     immunity to rubella or mumps;
                                     second dose for selected groups
Varicella                            Doses 1 and 2, at least 4 weeks apart      I have had chicken pox.
                                     for susceptible adults (no history of      I have had a vaccine for chicken pox.
                                     natural disease or seronegativity). A     #1 dose –
                                     history of chickenpox infection is
                                     adequate evidence of varicella            #2 dose –
                                     immunity. Serologic testing should be
                                     performed in adults without a history
                                     of disease, as the majority of such
                                     adults will be immune and do not
                                     require the varicella vaccine.
Influenza                            Every autumn using current                Test date:
                                     recommended vaccine formulation
Hepatitis B vaccine                  A series of three injections over a six   #1 dose –
                                     month period. The second dose             #2 dose –
                                     should be administered at least 1         #3 dose –
                                     month after the first dose, and the       Hepatitis B Antibody Serology:
                                     third at least 2 months after the         Date:
                                     second dose.                              Result:
TB/Mantoux Skin test                 A Two-step Tuberculin skin (TST) test     TB/Mantoux skin test date:
                                     must be completed and must be
                                     If there is a documented prior positive   Result date:
                                     TST, previous treatment for active
                                     TB, or previous treatment for latent
                                     TB, a TST is not required. Medical         Not significant
                                     evaluation and a chest X-ray within 1      Significant
                                     year (if asymptomatic) are required.       Chest x-ray done

Adapted from Canadian Immunization Guide, Seventh Edition, 2006

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Date:                                    Student Signature:

Date:                                    Regional Health Unit/ Health Provider Signature:

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