Information

• Full Name: __________________________________________
• Date of Birth: ____ / ____ / ______
• Age: _______
• Gender: ☐ Male ☐ Female ☐ Other
• Parent/Guardian Name (if under 18): _________________________
• Contact Number: ______________________________________

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Vaccination History Review

☐ Vaccination records reviewed
☐ Records unavailable – history taken verbally
☐ Referred for catch-up schedule

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Recommended Adolescent Vaccines (per national & WHO guidelines)

Counselor to tick and discuss applicable vaccines:

Vaccine	Discussed	Recommended	Administered
HPV (Human Papillomavirus)	☐	☐	☐
Tdap (Tetanus, Diphtheria, Pertussis)	☐	☐	☐
Meningococcal	☐	☐	☐
Hepatitis A	☐	☐	☐
Hepatitis B	☐	☐