HomeMy WebLinkAboutironisha shot records Perscmal immunization Record Page 1 of 1
Port Arthur City HD
Thursday, July 12, 2012
Personal Immunization Record
Patient's Name: MOUTON, IRONISHA Birthdate: 03/17/1994
Parent/Guardian: _ IMMTRAC Consent: Unknown
Address: 3513 THOMAS BLVD Chart No:
PORT ARTHUR, TX 77642 Client ID: 5738864
Vaccine Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6
DTaP 03/10/1997 08/26/1998
DTP / H I B 08/12/1994 11/11/1994
Hep 13 - Pedi 03/18/1994 04/15/1994 11/11/1994
H i b 03/10/1997
Measles, Mumps, Rubella 03/10/1997 08/26/1998
Meningococcal Conjugate 07/12/2012
Oral Polio Vaccine 08/12/1994 11/11/1994 03/10 /1997 08/26/1998
Varicella 08/26/1998
PPD Tests 03/10/1997 08/14/2001
Results NR 91620mm NEG
MEDICAL EXEMFT1ONS:
Port Arthur City HD
PORT ARTHUR CITY HEALTH DEPT
449 AUSTIN AVE D Ep�.
al PORT ARTHUR. TX 77640 TH11R
PRI +SEAL
409- 983 -8800 pF -P449 A T1N ATX 7/640
vows A[tTHt
Certified By Date ifibjlit.ij Phone
Older revisions of khis form already on file for students in school should not be replaced.
https://www.twi ;es.dshs.state.tx.us/twices/Immun/ImmPersonalImmForm.asp?Language=... 7/12/2012