"Immunization Record Form" - Missouri

Immunization Record Form is a legal document that was released by the Missouri Department of Mental Health - a government authority operating within Missouri.

Form Details:

  • The latest edition currently provided by the Missouri Department of Mental Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download "Immunization Record Form" - Missouri

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IMMUNIZATION RECORD
NAME
CASE NUMBER
DATE
TETANUS-DIPHTHERIA
(If the client has already been vaccinated, indicate the date of the DPT or Td Series was completed under “primary”.)
PRIMARY
2 MONTHS
4 MONTHS
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
TETANUS BOOSTER
(A Tetanus Booster will be given at least once every ten years)
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
MEASLES, MUMPS, RUBELLA
(If the client has history of disease or has already been vaccinated, please indicate the date/dates.)
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
HEPATITIS B
(The primary dosage should be given as soon as the results of the screening are available. If the vaccination is not necessary, indicate the
date and result of the screening under “primary”.)
PRIMARY
1 MONTH
6 MONTHS
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
INFLUENZA
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
PNEUMOVAX
(This vaccination is given only once to clients who, in the physician’s opinion, are a high risk for Pneumonia.)
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
TUBERCULIN TESTING RECORD
Clients will be tested yearly for Tuberculosis using the Mantoux Method. Clients who have a positive PPD will be
followed up with
a Chest X-Ray and then be X-rayed on a yearly basis.
PPD
DATE
READING
DATE
READING
IMMUNIZATION RECORD
NAME
CASE NUMBER
DATE
TETANUS-DIPHTHERIA
(If the client has already been vaccinated, indicate the date of the DPT or Td Series was completed under “primary”.)
PRIMARY
2 MONTHS
4 MONTHS
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
TETANUS BOOSTER
(A Tetanus Booster will be given at least once every ten years)
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
MEASLES, MUMPS, RUBELLA
(If the client has history of disease or has already been vaccinated, please indicate the date/dates.)
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
HEPATITIS B
(The primary dosage should be given as soon as the results of the screening are available. If the vaccination is not necessary, indicate the
date and result of the screening under “primary”.)
PRIMARY
1 MONTH
6 MONTHS
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
INFLUENZA
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
PNEUMOVAX
(This vaccination is given only once to clients who, in the physician’s opinion, are a high risk for Pneumonia.)
DOSAGE
DATE
DOSAGE
DATE
DOSAGE
DATE
TUBERCULIN TESTING RECORD
Clients will be tested yearly for Tuberculosis using the Mantoux Method. Clients who have a positive PPD will be
followed up with
a Chest X-Ray and then be X-rayed on a yearly basis.
PPD
DATE
READING
DATE
READING