Rocky Mountain Travel Medicine Clinic

Rocky Mountain Travel Medicine Clinic

Vaccination Record

Name: DOB: ______

HEPATITIS A Dose #1- Date __/__/____

□ Havrix/GSKLot#______Exp: ____/____ Dose □ 1ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

HEPATITIS A Dose #2- Date __/__/____

□ Havrix/GSKLot#______Exp: ____/____ Dose □ 1ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

*Note: Dose 1 is now; Dose 2 is 6 months to 18 months later.

*Children 12-18 yrs the dose is 0.5 ml.

HEPATITIS B Dose #1- Date __/__/____

□ Engerix/GSK Lot#______Exp: ____/____ Dose □ 1ml

Recombivax/Merck Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

HEPATITIS B Dose #2- Date __/__/____

□ Engerix/GSKLot#______Exp: ____/____ Dose □ 1ml

Recombivax/MerckRoute: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

HEPATITIS B Dose #3- Date __/__/____

□ Engerix/GSKLot#______Exp: ____/____ Dose □ 1ml

Recombivax/MerckRoute: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

*Note: Dose 1 is now, Dose 2 is in 1 month, and Dose 3 is 6 months after dose # 1.

*Birth to 19 yrs the dose is 0.5 ml. and the dose is (0, 1, 6 mths), adolescents (0, 4-6 mths).

TWINRIX A& B Dose #1- Date __/__/____

□ GlaxoSmith KlineLot#______Exp: ____/____ Dose □ 1ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

TWINRIX A& B Dose #2- Date __/__/____

□ GlaxoSmith KlineLot#______Exp: _____/____ Dose 1ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

TWINRIX A& B Dose #3- Date __/__/____

□ GlaxoSmith KlineLot#______Exp: ____/____ Dose □ 1ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

*Note: Accelerated is now, 7 days, 21-30 days, booster in 12 months.

Standard is now, 1 month, 6 months.

TETANUS/

DIPTHERIA Date __/__/____

□ Decavac/Lot#______Exp: ____/____ Dose □ 0.5ml

□Sanofi PasteurRoute: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

ADACEL (DTAP) Date __/__/____

□ SanofiPasteurLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

TETANUS

TOXOID Date __/__/____

□ Sanofi PasteurLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

TYPHOID/

ORAL Date __/__/____

□ Vivotiff/BernaLot#______Exp: ____/____ Dose □ 4 pills

Route: □ oralSide: N/ASite: N/A Initials: ____

TYPHOID/

INJECTABLE Date __/__/____

□ Typhim V/AventisLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

MENINGOCOCCAL Date __/__/____

□ Menactra/AventisLot#______Exp: ____/____ Dose □ 0.5ml

Menveo/Novartis Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: 0.5ml

____

□ Menomune/AventisLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ SQ Side: □ Right □ Left Site: □ Arm Initials: ____

Diluent Lot #______Exp: ____/____

PNEUMOCOCCAL Date __/__/____

□ PneumovaxLot#______Exp: ____/____ Dose □ 0.5ml

Merck & Co. Route: □ IM □SQ Side: □ Right □ LeftSite: □ Deltoid □ Arm Initials: ___

YELLOW FEVER Date____/____/_____

□ Sanofi Pasteur Lot#______Exp: ____/____ Dose □ 0.5ml

Route: □ SQ Side: □ Right □ Left Site: □ Arm Initials: ____

Diluent Lot #______Exp: ____/____

POLIODate __/__/____

□ Sanofi PasteurLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ IM □SQ Side: □ Right □ LeftSite: □ Deltoid□ Arm Initials: ___

RABIES Dose #1- Date __/__/____

□ Rabavert/Chiron Lot#______Exp: ____/____ Dose □ 1ml

Aventis Pasteur Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

RABIES Dose #2- Date __/__/____

□ Rabavert/Chiron Lot#______Exp: ____/____ Dose □ 1ml

Aventis Pasteur Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

RABIES Dose #3- Date __/__/____

□ Rabavert/Chiron Lot#______Exp: ____/____ Dose □ 1ml

Aventis Pasteur Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ____

*Note: Dose 1 is now, Dose 2 is in 7 days, and Dose 3 is in 21 to 28 days.

JAPANESE Dose #1- Date __/__/____

ENCEPHALITIS

□ JE Vax/ AventisLot#______Exp: ____/____ Dose □ 1ml

Diluent Lot# ______Exp: ____/____

Route: □ SQ Side: □ Right □ Left Site: □ Arm Initials: ____

JAPANESE Dose #2- Date __/__/____

ENCEPHALITIS

□ JE Vax/ AventisLot#______Exp: ____/____ Dose □ 1ml

Diluent Lot# ______Exp: ____/____

Route: □ SQ Side: □ Right □ Left Site: □ Arm Initials: ____

JAPANESEDose #3- Date __/__/____

ENCEPHALITIS

□ JE Vax/ AventisLot#______Exp: ____/____ Dose □ 1ml

Diluent Lot# ______Exp: ____/____

Route: □ SQ Side: □ Right □ Left Site: □ Arm Initials: ____

*Note: Dose 1 is now, Dose 2 is in 7 days, and Dose 3 is in 30 days ……Children 1-3 yrs. 0.5 ml.

VARICELLA

(CHICKEN POX) Date____/____/_____

□MerckLot#______Exp: ____/____ Dose □ 0.65ml

Route: □ SQ Side: □ Right □ Left Site: □ Arm Initials:____

VARIVAX Dose #1 Date____/____/_____

□MerckLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ SQ Side: □ Right □ Left Site: □ Arm Initials: ____

VARIVAX Dose #2 Date____/____/_____

□MerckLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ SQ Side: □ Right □ Left Site: □ Arm Initials: ___

*Note: Children (age 1-12) get 1 dose, Adolescents & Adults get 0.5 ml. now, Dose 2 is 4-8 wks after

MEASLES, MUMPS

RUBELLA (MMR)Date __/__/____

□MerckLot#______Exp: ____/____ Dose □ 0.5ml

Route: □SQ Side: □ Right □ LeftSite: □ Arm Initials: ___

HAEMOPHILUS

INFLUENZA (HIB) Date __/__/____

□ Sanofi PasteurLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ___

INFLUENZA Date __/__/____

□ Sanofi PasteurLot#______Exp: ____/____ Dose □ 0.5ml

Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ___

TUBERCULOSIS

(PPD) Date __/__/____

□ Sanofi PasteurLot#______Exp: ____/____ Dose □ 0.1ml

Route: □ ID Side: □ Right □ Left Site: □ Arm Initials: ___

IMMUNO-

GLOBULINDate __/__/____

□ BaygamLot#______Exp: ____/____ Dose □ per wt Route: □ IM Side: □ Right □ Left Site: □ Deltoid Initials: ___