Patient’s Name __________________ Patient’s Date of Birth ___/__/____
ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs)
Revised 10/24/2003
StateID: __ __ __ __ __ __ __
Date of positive culture ____/____/_____ Date form completed ____/____/_____
- VACCINE
HISTORY -
Child has never received vaccines
Vaccination history unknown
VACCINES |
Dose # |
Dates of immunizations |
Manufacturer |
Vaccine name |
Lot # |
Pneumococcal conjugate vaccine (Prevnar®) |
1 |
|
|
|
|
2 |
|
|
|
|
|
3 |
|
|
|
|
|
4 |
|
|
|
|
|
Pneumococcal polysaccharide vaccine (Pneumovax® 23) |
1 |
|
|
|
|
2 |
|
|
|
|
|
Diphtheria/Tetanus/ Pertussis (DTP or DtaP) |
1 |
|
|
|
|
2 |
|
|
|
|
|
3 |
|
|
|
|
|
4 |
|
|
|
|
|
5 |
|
|
|
|
|
Haemophilus influenza type B (Hib) |
1 |
|
|
|
|
2 |
|
|
|
|
|
3 |
|
|
|
|
|
4 |
|
|
|
|
|
Influenza vaccine
|
1 |
|
|
|
|
2 |
|
|
|
||
3 |
|
|
|
*For combination vaccines (e.g. Trihibit, Tetramune, ActHIB/DTwP) enter information for each vaccine component
- IMMUNE
SYSTEM EVALUATION-
Does this patient have an immune disorder other than HIV or AIDS? □ Yes □ No □ Unknown
If yes, diagnosis _________________________
If yes, indicate below results for any tests performed to evaluate immune function:
Tests Test Date Result
IgGtotal..……………___/___/_____ □ Low □ Normal □ High □ Not done
IgG1…………………___/___/_____ □ Low □ Normal □ High □ Not done
IgG2…………………___/___/_____ □ Low □ Normal □ High □ Not done
IgG3…………………___/___/_____ □ Low □ Normal □ High □ Not done
IgG4…………………___/___/_____ □ Low □ Normal □ High □ Not done
IgM………………….___/___/_____ □ Low □ Normal □ High □ Not done
IgA…………………..___/___/_____ □ Low □ Normal □ High □ Not done C3……………………___/___/_____ □ Low □ Normal □ High □ Not done
C4……………………___/___/_____ □ Low □ Normal □ High □ Not done
CH50………………...___/___/_____ □ Low □ Normal □ High □ Not done
Other (specify_____________)___/___/_____ □ Low □ Normal □ High □ Not done
Other (specify_____________)___/___/_____ □ Low □ Normal □ High □ Not done
Person completing the form (please print): Phone: ( )______________
Name ___________________Title ___________ Fax: ( )______________
Please return ______________________ Phone: ( )______________
form to: ______________________ Fax: ( )______________
______________________
File Type | application/msword |
File Title | PNEUMOCOCCAL CONJUGATE VACCINE EFFECTIVENESS STUDY |
Author | tdp4 |
Last Modified By | lhl4 |
File Modified | 2008-04-11 |
File Created | 2008-04-11 |