2/10/22, 7:08 AM Show Report - Kaiser Permanente

Member name: Stephanie Clara

Date of birth: 11/9/2009
Gender: F
Primary care physician: MARIA CECILIA GONZALEZ MD, M.D.
Date printed: 2/10/2022

DATE
DATE
VACCINE
GIVEN
DOCTOR OFFICE OR CLINIC
NEXT

vacuna
fecha de
médico o clinica
DOSE
vacunación DUE

próxima

vacuna
KAISER MR# 000019314393 PRINTED: 02/10/2022   05/27/2010 POL-IPV  
Name POL-IPV Kaiser Permanente
nombre CLARA,STEPHANIE   01/02/2014 DTAP-POL (KINRIX)  
Birthdate Sex DTAP-POL Kaiser Permanente
fecha de nacimiento 11/09/2009 sexo F ROTAVIRUS 01/20/2010 ROT5 ROTAVIRUS  
Allergies ROT5 Kaiser Permanente
alergias   03/22/2010 ROT5 ROTAVIRUS  
Vaccine Reactions ROT5 Kaiser Permanente
reacciones a la vacuna     05/27/2010 ROT5 (ROTATEQ)  
RETAIN THIS DOCUMENT __ CONSERVE ESTE ROT5 Kaiser Permanente
DOCUMENTO


PNEUMO 01/20/2010 PNUCN  
DATE DATE
NEXT
VACCINE GIVEN DOCTOR OFFICE OR DOSE DUE PNUCN Kaiser Permanente
CLINIC
vacuna fecha de médico o clinica próxima   03/22/2010 PNUCN  
vacunación
vacuna
PNUCN Kaiser Permanente
DTAP 01/20/2010 DTAP-HBV-POL     05/27/2010 PREVNAR 13  
DTAP-HBV-POL Kaiser Permanente PREVNAR Kaiser Permanente
  03/22/2010 DTAP-HBV-POL     11/13/2010 PREVNAR 13  
DTAP-HBV-POL Kaiser Permanente PREVNAR Kaiser Permanente
  05/27/2010 DTAP   HEPB 11/10/2009 HBV (PED/ADOL)  
DTAP Kaiser Permanente HBV Kaiser Permanente
  11/13/2010 DTAP     01/20/2010 DTAP-HBV-POL  
DTAP Kaiser Permanente DTAP-HBV-POL Kaiser Permanente
  01/02/2014 DTAP-POL (KINRIX)     03/22/2010 DTAP-HBV-POL  
DTAP-POL Kaiser Permanente DTAP-HBV-POL Kaiser Permanente
TDAP 12/29/2020 TDAP (ADACEL)     05/27/2010 HBV (PED/ADOL)  
TDAP Kaiser Permanente HBV Kaiser Permanente
HIB 01/20/2010 HIB PRP-T   HEPA 11/13/2010 HAV (PED/ADOL X2)  
HIB PRP-T Kaiser Permanente HAV Kaiser Permanente
  03/22/2010 HIB PRP-T     11/10/2011 HAV (PED/ADOL X2)  
HIB PRP-T Kaiser Permanente HAV Kaiser Permanente
  05/27/2010 HIB VACCINE   MUMPS,MEASLES,RUBELL 11/13/2010 MMR  
HIB Kaiser Permanente MMR Kaiser Permanente
  11/13/2010 HIB VACCINE     01/02/2014 MMRV VACCINE  

HIB Kaiser Permanente MMRV Kaiser Permanente

POLIO 01/20/2010 DTAP-HBV-POL   VZV 11/13/2010 VAR  
DTAP-HBV-POL Kaiser Permanente VAR Kaiser Permanente
  03/22/2010 DTAP-HBV-POL        
DTAP-HBV-POL 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 TB SKIN TESTS¹ Pruebas de la Tuberculosis
vacunas par asistar a la escuela

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) PPD
05/20/2013   05/22/2013   0 NEG
HEPA [difteria,tetano,y los forino]

= Hepatitis A
HEPB
= Hepatitis B
PPD
__/__/____   __/__/____      
HIB = HIB Meningitis (Haemophilius influenzae type
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2/10/22, 7:08 AM Show Report - Kaiser Permanente
g ( p yp
B) [meningitis Hib]
HPV
= Human papilloma virus [viris del papiloma PPD
__/__/____   __/__/____      
INFV humana]

= 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 ² If required for school entry, must be Mantoux unless exception granted by local health
rubeola] 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 ________________________________

IMMUNIZATION RECORD Continuation Form

Comprobante de Imunizacion - Pagina de KAISER 000019314393 PRINTED: 02/10/2022
Continuacion MR#
Name
nombre CLARA,STEPHANIE Page#2

DATE DATE DATE DATE

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2/10/22, 7:08 AM Show Report - Kaiser Permanente
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