Template for immunizations for transplant patients

Vaccinations/Immunizations:

Ever Received                  Date Completed               Date of Last Shot

Hepatitis A

Hepatitis B

Tetanus or TDAP

Shingles (Zostavax) (or if Varicella positive)

Pneumonia

Influenza

Serologic data:

VZV:

EBV:

CMV:

RPR/trep Ab:

HIV:

Measles titer:

Mumps:

Rubella:

T-SPOT.TB:

Strongy:

Hepatitis data:

HAV Ab:

HBV sAb:

HBV sAg:

HBV cAb:

HCV Ab:

VACCINATION PLAN

Today                                  Return Visit 1             Return Visit 2

Hepatitis A

Hepatitis B (high dose)

Influenza

Menactra

MMR

PCV13

PPV23

TDAP

Varicella

Zostavax

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