Immunization History

Please print form, fill out completely and fax to (518) 783-2992 or mail to:

 

 
NAME:
 
Record individual dates of each dose
Measles If born after 1/1/57, two doses of live vaccine required. First vaccine must be given after 1967 and on or after first birthday, second dose at least three months later. Serologic proof of immunity is acceptable or date of measles disease.Submit copy of serology resluts.  
Mumps If born on or after 1/1/57, one dose of live vaccine given on or after first birthday. Serologic proof of immunity is acceptbale or date of mumps disease. Submit copy of positive serologic results.  
 
 
Rubella If born on or after 1/1 57, one dose of live vaccine given on or after first birthday. Serologic proof of immunity is acceptbale or date of disease is unacceptable. Submit copy of positive serologic results.  
 
Diptheria/Tetanus Basic series of three doses. Most recent dose must be within ten years.  
 
 
   
Polio Vaccine Three doses of Trivalent Oral Polio (TOPV) or four doses of Inactivated Polio Vaccine (IPV) or three doses of Enhanced Polio Vaccine (EIPV).      
Hepatitus B Series of three doeses at 0, 1, and 5 months.  
 
 
   
Tuberculin PPD (Mannoux). Must be within 6 months.  
Date _____________       Results __Neg.   __Pos.

__________________mm.

If BCG given, PPD required.  
BCG Date __________     Results __Neg.   __Pos.

__________________mm.

If PPD positive, Chest x-ray required.  
Date _____________     Results _______________
 

Go to, Medical History Check List