Page 1 of 1 VACCINE vacuna KAISER MR# 000019814972 PRINTED: 02/04/2015 DATE GIVEN fecha de vacunación DATE NEXT DOSE DUE próxima vacuna DOCTOR OFFICE OR CLINIC médico o clinica Name YOUNG,BRIDGETTE J nombre Birthdate Sex sexo F 03/28/1991 fecha de nacimiento Allergies alergias Vaccine Reactions reacciones a la vacuna RETAIN THIS DOCUMENT VACCINE vacuna ___ CONSERVE ESTE DOCUMENTO DATE GIVEN DOCTOR OFFICE OR CLINIC DATE NEXT DOSE DUE fecha de médico o clinica próxima vacunación vacuna 08/07/2012 TDAP (ADACEL) TDAP Kaiser Permanente TDAP POL-IPV 06/28/2011 POL-IPV Kaiser Permanente HPV4 HUMAN 08/07/2012 HPV4 HUMAN PAPILLOMA Kaiser Permanente POLIO HPV MENINGOCOCCAL 06/28/2011 MENCN, GRPS A,C,Y & W-135 MENCN GRPS Kaiser Permanente INFLUENZA INFS 4YRS 11/08/2013 INFS 4YRS+ (FLUVIRIN) Kaiser Permanente 06/28/2011 TYDVI TYPHOID Kaiser Permanente TYDVI YELLOW FEVER YF 06/28/2011 YF Kaiser Permanente Chickenpox Parents: Padres: DT/Td DTaP/Tdap DTP HEPA HEPB HIB HPV INFV MENINGOCOCCAL MMR PNEUMO POLIO RV VZV Your child must meet California's immunization requirements to be enrolled in school and child care.Keep this Record as proof of immunization. Su niño debe cumpar con los requisitos de vacunas par asistar a la escuela y a la guarderia. Marienga esta Comprobanta lo necesitana. = Diphteria,tetanus [difteria,tetano] = Diphteria,tetanus,pertussis(whooping cough)[difteria,tetano,y los forino] = Diphteria,tetanus,pertussis(whooping cough)[difteria,tetano,y los forino] = Hepatitis A = Hepatitis B = HIB Meningitis (Haemophilius influenzae type B) [meningitis Hib] = Human papilloma virus [viris del papiloma humana] = Influenza [la gripa] = Meningococcal vaccine [vacuna meningococia] = Measles, mumps, rubella [sarampion, papras rubeola] = Pneumococcae vaccine [pneumococica] = Poliomielitis [poliomielitis] = Rotavirus [rotavirus] = Varicella (chickenpox) [varicela] TB SKIN TESTS¹ Pruebas de la Tuberculosis Type² Date given Given by Date read PPD __/__/____ 07/15/2013 PPD __/__/____ __/__/____ PPD __/__/____ __/__/____ Read by mm/indur Impression 0 NEG ¹ A chest x-ray may be indicated if skin test is positive. ² If required for school entry, must be Mantoux unless exception granted by local health department. CHEST X-RAY Film date: ____/____/____ Interpretation: [ ]normal [ ]abnormal [Radiografia] Person is free of communicable tuberculosis [ ]yes [ ]no (Necessary if skin test positive.) Signature/Agency ________________________________ Kaiser Permanente, SCPMG: Young, Bridgette J (000019814972) Page 1 of 1
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