State Form 49969 - Child Care Center Health Record Page 2
ADVERTISEMENT
1
2HISTORY OF IMMUNIZATIONS AND TEST (indicate month / day / year)
1
2
3
4
5
DTaP / DT
1
2
3
4
Hib
1
2
3
4
5
IPV (Polio)
1
2
3
4
5
Influenza (Flu)
*
1
2
Measles Mumps
Rubella (MMR)
1
2
3
Rotavirus (RGE)
1
2
Month / year
Varicella
or Chicken Pox Disease
(Varivax)
1
2
3
4
Pneumococcal
(PCV) (Prevnar)
1
2
HEPA
1
2
3
HBV
(HEP B)
*
Recommended yearly.
Name of physician / nurse practitioner completing form (please print)
Telephone number
(
)
Signature of physician / nurse practitioner
ADDITIONAL NOTES AND INSTRUCTIONS
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical