Scribd
Upload
391 views2 pages

Health Immunization Record

This document is a health record and immunization record form. It contains fields to log information about various vaccinations a patient has received, including dates, locations, batch numbers, dosages, and physicians' names. Vaccinations that can be logged include smallpox, yellow fever, typhoid, tetanus-diphtheria, cholera, polio, influenza, and others. It also includes a section to record sensitivity test results and remarks. At the top, it prompts for patient identification details to be filled in.

Uploaded by

Thalinor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
391 views2 pages

Health Immunization Record

This document is a health record and immunization record form. It contains fields to log information about various vaccinations a patient has received, including dates, locations, batch numbers, dosages, and physicians' names. Vaccinations that can be logged include smallpox, yellow fever, typhoid, tetanus-diphtheria, cholera, polio, influenza, and others. It also includes a section to record sensitivity test results and remarks. At the top, it prompts for patient identification details to be filled in.

Uploaded by

Thalinor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

All entries in ink to be

HEALTH RECORD IMMUNIZATION RECORD


made in block letter
VACCINATION AGAINST SMALLPOX (Number of previous vaccination scars)
DATE ORGIN BATCH NUMBER REACTION STATION PHYSICIAN'S NAME

6
YELLOW FEVER VACCINE
DATE ORGIN BATCH NUMBER STATION PHYSICIAN'S NAME

3
TYPHOID VACCINE
DATE DOSE PHYSICIAN'S NAME DATE DOSE PHYSICIAN'S NAME

1 4

2 5

3 6
TETANUS-DIPHTHERIA TOXOIDS
DATE DOSE PHYSICIAN'S NAME DATE DOSE PHYSICIAN'S NAME

1 4

2 5

3 6
CHOLERA VACCINE
DATE PHYSICIAN'S NAME DATE PHYSICIAN'S NAME DATE PHYSICIAN'S NAME

1 4 7

2 5 8

3 6 9
PATIENT'S IDENTIFICATION (Mechanically Imprint, Type or Print):
Patients's Name--last, first, middle initial;
Sex, Age or Year of Birth; Relationship to Sponsor;
Component/ Status; Department/ Service.

Sponsor's Name--last, first, middle initial;


Rank/Grade; SSN or Identification Number;
Organization.
IMMUNIZATION RECORD
Standard Form 601--October 1975 (Rev.)
601-105 General Services Administration & Interagency
Committee on Medical Records
FIRMR (4) CFR) 201-45.505
ORAL POLIOVIRUS VACCINE
DATE DOSE PHYSICIAN'S NAME DATE DOSE PHYSICIAN'S NAME

1 3

2 4
INFLUENZA VACCINE
DATE DOSE PHYSICIAN'S NAME DATE DOSE PHYSICIAN'S NAME

1 3

2 4
OTHER IMMUNIZATIONS
DATE DOSE PHYSICIAN'S NAME DATE DOSE PHYSICIAN'S NAME

1 5

2 6

3 7

4 8
SENSITIVITY TEST (Tuberculin, etc.)
DATE TYPE DOSE ROUTE RESULTS PHYSICIAN'S NAME

REMARKS:

THIS RECORD IS ISSUED IN ACCORDANCE WITH ARTICLE 99, WHO SANITARY REGULATION NO.2
* U.S.GPO:1997-427-590/69093

You might also like