6/22/2020 Show Report - Kaiser Permanente
DATE DATE NEXT
VACCINE GIVEN DOCTOR OFFICE OR CLINIC DOSE DUE
vacuna fecha de médico o clinica próxima
vacunación vacuna
KAISER MR# 110011326042 PRINTED: 06/22/2020 02/25/2003 HIB PRP-T
Name HIB PRP-T Kaiser Permanente
nombre VO,JUSTIN D 05/28/2003 HIB PRP-T
Birthdate Sex HIB PRP-T Kaiser Permanente
fecha de nacimiento 05/28/2002 sexo M HPV 08/13/2015 HPV9
Allergies HPV9 Kaiser Permanente
alergias 07/20/2016 HPV9
Vaccine Reactions HPV9 Kaiser Permanente
reacciones a la vacuna INFLUENZA 12/23/2004 INFS
RETAIN THIS DOCUMENT __ CONSERVE ESTE DOCUMENTO INFS Kaiser Permanente
10/27/2005 INFS
DATE DATE NEXT
VACCINE GIVEN DOCTOR OFFICE OR CLINIC DOSE DUE INFS Kaiser Permanente
vacuna fecha de médico o clinica próxima 11/11/2010 INFS PF 3YRS+
vacunación vacuna INFS PF Kaiser Permanente
DTP 07/29/2002 DTAP 10/06/2012 INFS PF 3YRS+
DTAP Historical records INFS PF Kaiser Permanente
09/27/2002 DTAP MENING 04/09/2015 MENCN, GRPS A,C,Y &
DTAP Kaiser Permanente MENCN GRPS Kaiser Permanente
01/16/2003 DTAP 02/21/2020 MCV4O (MENVEO)
DTAP Kaiser Permanente MCV4O Kaiser Permanente
03/16/2004 DTAP 02/21/2020 MEN-B OMV
DTAP Kaiser Permanente MEN-B OMV Kaiser Permanente
06/23/2006 DTAP MMR 05/28/2003 MMR
DTAP Kaiser Permanente MMR Kaiser Permanente
HEP A 06/21/2004 HAV (PED/ADOL X2) 06/23/2006 MMR
HAV Kaiser Permanente MMR Kaiser Permanente
07/18/2005 HAV (PED/ADOL X2) PNEUMO 07/29/2002 PNUCN
HAV Kaiser Permanente PNUCN Historical records
HEP B 05/28/2002 HEP B VAC 09/27/2002 PNUCN
HEP B VAC Historical records PNUCN Kaiser Permanente
06/28/2002 HEP B VAC 11/21/2002 PNUCN
HEP B VAC Historical records PNUCN Kaiser Permanente
01/16/2003 HEP B VAC 05/28/2003 PNUCN
HEP B VAC Kaiser Permanente PNUCN Kaiser Permanente
HIB 07/29/2002 HIB HBOC POLIO 07/29/2002 POL-IPV
HIB HBOC Historical records POL-IPV Historical records
11/21/2002 HIB PRP-T
HIB PRP-T Kaiser Permanente Chickenpox
Parents: Your child must meet California's immunization requirements to be enrolled
in school and child care.Keep this Record as proof of immunization.
Padres: Su niño debe cumpar con los requisitos de vacunas par asistar a la escuela TB SKIN TESTS¹ Pruebas de la Tuberculosis
y a la guarderia. Marienga esta Comprobanta lo necesitana.
DT/Td = Diphteria,tetanus [difteria,tetano] Type² Date given Given by Date read Read by mm/indur Impression
DTaP/Tdap = Diphteria,tetanus,pertussis(whooping cough)[difteria,tetano,y los forino]
DTP = Diphteria,tetanus,pertussis(whooping cough)[difteria,tetano,y los forino] PPD 07/18/2005 7127952 07/21/2005 00 NEG
HEPA = Hepatitis A
HEPB = Hepatitis B PPD __/__/____ __/__/____
HIB = HIB Meningitis (Haemophilius influenzae type B) [meningitis Hib]
HPV = Human papilloma virus [viris del papiloma humana] PPD __/__/____ __/__/____
INFV = Influenza [la gripa]
MENINGOCOCCAL = Meningococcal vaccine [vacuna meningococia] ¹ A chest x-ray may be indicated if skin test is positive.
MMR = Measles, mumps, rubella [sarampion, papras rubeola] ² If required for school entry, must be Mantoux unless exception granted by local health department.
PNEUMO = Pneumococcae vaccine [pneumococica] CHEST X-RAY Film date: ____/____/____ Interpretation: [ ]normal [ ]abnormal
POLIO = Poliomielitis [poliomielitis] [Radiografia] Person is free of communicable tuberculosis [ ]yes [ ]no
RV = Rotavirus [rotavirus] (Necessary if skin test positive.)
VZV = Varicella (chickenpox) [varicela]
Signature/Agency ________________________________
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6/22/2020 Show Report - Kaiser Permanente
IMMUNIZATION RECORD Continuation Form
Comprobante de Imunizacion - Pagina de Continuacion KAISER MR# 110011326042 PRINTED: 06/22/2020
Name
nombre VO,JUSTIN D Page#2
DATE DATE NEXT DATE DATE NEXT
VACCINE GIVEN DOCTOR OFFICE OR CLINIC DOSE DUE VACCINE GIVEN DOCTOR OFFICE OR CLINIC DOSE DUE
vacuna fecha de médico o clinica próxima vacuna fecha de médico o clinica próxima
vacunación vacuna vacunación vacuna
09/27/2002 POL-IPV
POL-IPV Kaiser Permanente
11/21/2002 POL-IPV
POL-IPV Kaiser Permanente
06/23/2006 POL-IPV
POL-IPV Kaiser Permanente
TDAP/TD 10/22/2012 TDAP (ADACEL)
TDAP Kaiser Permanente
CHICKENPOX 05/28/2003 VAR
VAR Kaiser Permanente
12/15/2006 VAR
VAR Kaiser Permanente
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