Form 74.1 Log

OMB Control Number 0925 0593
Expiration Date: 07/31/2013

Infant and Child Health Care Log
Birth to 6 years old
BRING THIS LOG TO ALL HEALTH CARE VISITS. USE THIS LOG
FOR ALL STUDY TELEPHONE CALLS AND VISITS.
PLEASE TELL NCS STAFF WHEN MORE FORMS ARE NEEDED.

Save all bottles and containers of medications. Bring to Study
visits and have available for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

CHILD’S LAST NAME

CHILD’S FIRST NAME

/

CHILD’S DATE OF BIRTH:
mm

/
dd

yyyy

Public reporting for this collection of information is estimated to average 20 minutes per response including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.

Infant and Child Health Care Log

This Infant and Child Health Care Log will help you keep track of all your
child’s visits to doctors or other health care providers from birth to 6 years
old. We will ask you about your child’s visits whenever we interview you by
telephone or in person.
A Health Care Provider can be:
• Pediatrician or family medicine doctor
• Specialist (like a surgeon, heart doctor, allergy or skin doctor)
• Nurse practitioner or physician assistant
• Nurse
• Social worker/counselor
• Other
Health Care Visits can be to:
• Doctor’s office, clinic or health center
• Emergency room
• Urgent care center
• Hospital (inpatient, overnight stay)
• Some other place
The log has two parts:

Health Care Provider Log Instructions
The Health Care Provider is the person who cared for your child at this visit
(doctor, nurse, social worker, etc.)
Column 1

A number is listed for each health care provider (for example,
1, 2, 3, 4, etc.). This number will be referred to on the Health
Care Visit Log pages.

Column 2

Attach the health care provider’s business card here.

Fill in columns 3-10 only if you have not attached the health care
provider’s business card.
Column 3

Write in the name of the health care provider.

Column 4

Check the box for the type of provider. If it was “Other,” write
the type of health care provider.

Column 5

Check the box for the type of place where you saw the provider.
If it was “Other place,” write in the type of place where your
child visited the health care provider.

Columns 6-9

Write in the address of the place including city/town, state, and
ZIP code.

Column 10

Write in the telephone number of the health care provider
including area code.

1. Health Care Provider Log is to record information about where your
child visits the doctor or other health care provider.
2. Health Care Visit Log is to record information about all of your child’s
visits to doctors, other healthcare providers, or an emergency room. This
includes overnight hospital stays as well as outpatient visits.
BRING this Infant and Child Health Care Log with you to all of your child’s
health care and National Children’s Study visits. Also, have it available for all
National Children’s Study telephone interviews.
If you forget to bring it with you to a health care visit, please fill it in as soon
as possible.
Save all bottles and containers of medications and bring to National
Children’s Study visits and have available for telephone calls:
• Medicines (those prescribed by a health care provider and those bought
“over -the-counter”)
• Vitamins, minerals, herbs, and any other supplements

See the example in the first line of the log on the next page.
After you fill out the Health Care Provider Log, please fill out the Health
Care Visit Log.
Inform the National Children’s Study staff when more Log pages are needed.

The National Children’s Study

Infant and Child Health Care Log

Health Care Provider Log
1

Fill in ONLY if you HAVE NOT attached a business card
3

4

5

6

7

8

9

10

Name of Health Care
Provider/Clinic/Hospital

Type of
Health Care
Provider

Type of Place

Street Address

City or Town

State

ZIP
Code

Telephone
Number

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

400 Main
Street

Capitol
City

1

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

2

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

3

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

Health Care
Provider
Number

0

2
Attach Health Care Provider
Business Card

Dr. Joe Jones

EXAMPLE

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Please remember to fill out the Health Care Visit Log.
Inform the National Children’s Study staff when more pages are needed.

123MN 56087 (507)
4567

The National Children’s Study

Infant and Child Health Care Log

Health Care Provider Log
1

3

4

5

6

7

8

9

10

Name of Health Care
Provider/Clinic/Hospital

Type of
Health Care
Provider

Type of Place

Street Address

City or Town

State

ZIP
Code

Telephone
Number

4

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

5

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

6

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

7

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

Health Care
Provider
Number

2

Fill in ONLY if you HAVE NOT attached a business card

Attach Health Care Provider
Business Card

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Please remember to fill out the Health Care Visit Log.
Inform the National Children’s Study staff when more pages are needed.

The National Children’s Study

Infant and Child Health Care Log

Health Care Provider Log
1

3

4

5

6

7

8

9

10

Name of Health Care
Provider/Clinic/Hospital

Type of
Health Care
Provider

Type of Place

Street Address

City or Town

State

ZIP
Code

Telephone
Number

8

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

9

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

10

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

11

☐ Pediatrician or
Family Physician
☐ Specialist
☐ Nurse practitioner
or physician
assistant
☐ Nurse
☐ Social Worker/
counselor
☐ Other (specify):

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital
☐ Other place
(specify):

Health Care
Provider
Number

2

Fill in ONLY if you HAVE NOT attached a business card

Attach Health Care Provider
Business Card

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Please remember to fill out the Health Care Visit Log.
Inform the National Children’s Study staff when more pages are needed.

Infant and Child Health Care Log

Health Care Visit Log Instructions
Office and Outpatient Visits and Overnight Hospital Stays
Each time your child goes to the doctor or any other health care provider (for example,
doctor, nurse, social worker, etc.) or is hospitalized overnight, write down information
about the visit on a new line in the Health Care Visit Log.
Please try to fill in columns 1-3 before the visit. If possible, ask your health care
provider or the office staff to fill out columns 4-10. If that is not possible, please fill
out columns 4-10 at the visit or as soon as possible.
Column 1

Health care visit date (month/day/year).

Column 2

Write the Health Care Provider number from Column 1 in the
Health Care Provider Log.

Column 3

Check (√) the reason(s) for the visit and explain if needed. Include
office/outpatient visits and overnight hospital stays. For example:
If your child got a well-baby check up, put a check (√) in the
“check-up/well child visit” box.

Column 4-6

Write in your child’s weight, and length or height at the visit. Write
in the head circumference through age 2. If these measurements
were not done, check (√) “Not Done.” For example: If your child is
22 inches long at his visit, write in “22” inches.

Column 7

If your child got an immunization/vaccination/shot during the visit,
put a check (√) in the “YES” box and Go to the Immunization/
Vaccination/Shot Log.

Column 8

If your child gets any test, medication, or treatment during his/her
visit, put a check (√) next to the medication/treatment and list each.

Column 9

Write what the health care provider told you (the diagnosis) at the
visit. Include a few key words to describe the event or diagnosis.
For example: For a check-up or well child visit, the doctor may have
told you that your child is ‘growing normally and is healthy’ or ‘has
an ear infection.’ Write this down in the ‘Diagnosis’ column.

Column 10

Check the box to show if the office staff filled out the log or if you
did. After you report the visit to the NCS study staff, please write in
the date you told us about that visit.

See the example in the first line of the log on the next page.
Inform the National Children’s Study staff when more Log pages are needed.

The National Children’s Study

Infant and Child Health Care Log

Log for Outpatient Health Care Visits and
Overnight Hospital Stays
1

2

Date
of visit

Health Care
Provider #
from
Health Care
Provider Log

March
3, 2011

0

3

Reason for visit
(check all that apply)

☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

4

5

6

Head
circumference
(0-2 yrs.)

Length/
Height

Weight

10 lb
4 oz.

23

7

37 in

in

pounds

inches

inches

ounces

OR

OR

cm
centimeters

OR
kg
kilograms

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

☐ Not Done/
Don’t Know
☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

lb
pounds
oz.
ounces

in
inches

OR

OR

cm
centimeters

OR
kg
kilograms

in

inches

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

Immunization/
Vaccination/
Shot

☐ No
☐ Yes

8
Tests/ Medications/
Treatments
e.g., lab tests (blood, urine…),
medicines, vitamins, minerals,
herbs, supplements, procedures

Lab test (blood)

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

9

10
Completed by
Office or Self

Diagnosis or Problem

Well infant,
good growth and
development

EXAMPLE

Date Reported
to National
Children’s Study

☐ Office
☐ Self

Date:

March 4, 2011

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ Not Done/
Don’t Know
☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

in

lb
pounds
oz.
ounces

inches

OR

OR

cm
centimeters

OR
kg
kilograms

in

inches

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

☐ Not Done/
Don’t Know

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Inform the National Children’s Study staff when more pages are needed.

The National Children’s Study

Infant and Child Health Care Log

Log for Outpatient Health Care Visits and
Overnight Hospital Stays
1

2

Date
of visit

Health Care
Provider #
from
Health Care
Provider Log

3

Reason for visit
(check all that apply)

☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

4

5

6

Head
circumference
(0-2 yrs.)

Length/
Height

Weight

lb
pounds
oz.
ounces

in

kg
kilograms

in

inches

inches

OR

OR

cm
centimeters

OR

7

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

Immunization/
Vaccination/
Shot

8
Tests/ Medications/
Treatments
e.g., lab tests (blood, urine…),
medicines, vitamins, minerals,
herbs, supplements, procedures

9

10
Completed by
Office or Self

Diagnosis or Problem

Date Reported
to National
Children’s Study

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ Not Done/
Don’t Know
☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

lb
pounds
oz.
ounces

in
inches

OR

OR

cm
centimeters

OR
kg
kilograms

in

inches

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

☐ Not Done/
Don’t Know
☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

in

lb
pounds
oz.
ounces

inches

OR

OR

cm
centimeters

OR
kg
kilograms

in

inches

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

☐ Not Done/
Don’t Know

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Inform the National Children’s Study staff when more pages are needed.

The National Children’s Study

Infant and Child Health Care Log

Log for Outpatient Health Care Visits and
Overnight Hospital Stays
1

2

Date
of visit

Health Care
Provider #
from
Health Care
Provider Log

3

Reason for visit
(check all that apply)

☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

4

5

6

Head
circumference
(0-2 yrs.)

Length/
Height

Weight

lb
pounds
oz.
ounces

in

kg
kilograms

in

inches

inches

OR

OR

cm
centimeters

OR

7

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

Immunization/
Vaccination/
Shot

8
Tests/ Medications/
Treatments
e.g., lab tests (blood, urine…),
medicines, vitamins, minerals,
herbs, supplements, procedures

9

10
Completed by
Office or Self

Diagnosis or Problem

Date Reported
to National
Children’s Study

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ Not Done/
Don’t Know
☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

lb
pounds
oz.
ounces

in
inches

OR

OR

cm
centimeters

OR
kg
kilograms

in

inches

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

☐ Not Done/
Don’t Know
☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

in

lb
pounds
oz.
ounces

inches

OR

OR

cm
centimeters

OR
kg
kilograms

in

inches

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

☐ Not Done/
Don’t Know

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Inform the National Children’s Study staff when more pages are needed.

The National Children’s Study

Infant and Child Health Care Log

Log for Outpatient Health Care Visits and
Overnight Hospital Stays
1

2

Date
of visit

Health Care
Provider #
from
Health Care
Provider Log

3

Reason for visit
(check all that apply)

☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

4

5

6

Head
circumference
(0-2 yrs.)

Length/
Height

Weight

lb
pounds
oz.
ounces

in

kg
kilograms

in

inches

inches

OR

OR

cm
centimeters

OR

7

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

Immunization/
Vaccination/
Shot

8
Tests/ Medications/
Treatments
e.g., lab tests (blood, urine…),
medicines, vitamins, minerals,
herbs, supplements, procedures

9

10
Completed by
Office or Self

Diagnosis or Problem

Date Reported
to National
Children’s Study

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ No
☐ Yes

☐ Office
☐ Self

If ‘YES’ then go
to Immunization/
Vaccination/
Shot Log

Date:

☐ Not Done/
Don’t Know
☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

lb
pounds
oz.
ounces

in
inches

OR

OR

cm
centimeters

OR
kg
kilograms

in

inches

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

☐ Not Done/
Don’t Know
☐ Routine well visit
☐ Sick visit
☐ Specialist doctor visit
☐ Emergency visit
☐ Immunization/ vaccination/
shot
☐ Follow-up visit
☐ Overnight hospital stay
How many nights?
☐ Some other reason
(explain):

in

lb
pounds
oz.
ounces

inches

OR

OR

cm
centimeters

OR
kg
kilograms

in

inches

☐ Not Done/
Don’t Know

cm
centimeters
☐ Not Done/
Don’t Know

☐ Not Done/
Don’t Know

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Inform the National Children’s Study staff when more pages are needed.

Infant and Child Health Care Log

Immunization/Vaccination/Shot Log Instructions
• Write in the date of the immunization/vaccination/shot.
• Put a √ in the box of each vaccine(s) given to your child. Ask your child’s
Health Care Provider to help you to check all of the right boxes.
• At the bottom of the Log, write in if your child had any problems after any of
the immunizations, vaccinations or shots.

See the example in the first line of the log on the next page.

Contact your child’s doctor if your
child has any problems after an
immunization/shot/vaccination.

The National Children’s Study

Infant and Child Health Care Log

1. Palivizumab to prevent RSV
(Respiratory Syncytial Virus)

Meningococcal

Hepatitis A

Varicella (Chickenpox)

DTaP , IPV, and Hib

DTaP and IPV

DTaP and Hib

Needle

Nasal
Mist

EXAMPLE

March 3, 2011

ANY PROBLEMS AFTER A SHOT/IMMUNIZATION/VACCINATION?
Date of the Immunization/Vaccination/Shot

Date you first noticed the problem

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Describe the problem

Inform the National Children’s Study staff when more pages are needed.

Other

By
Mouth

Combination
vaccines

Hib and Hep B

DTaP, Hep B, and IPV

Measles, Mumps, Rubella, and Varicella (MMRV)

DATE OF
IMMUNIZATION

Measles, Mumps, and Rubella (MMR)

Pneumococcal Conjugate (PCV7)

Inactivated Polio (IPV)

H. Influenza Type B (Hib)

Diphtheria, Tetanus, and Pertussis
(whooping cough) (DTaP)

Hepatitis B (Hep B)

Combination
vaccines

Influenza (Seasonal ‘Flu’)

Needles or injections

Rotavirus

Needles or injections

Influenza (Seasonal ‘Flu’)

Immunization/Vaccination/Shot Log

XYZ Vaccine

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
Centers for Disease Control and Prevention
U.S. ENVIRONMENTAL PROTECTION AGENCY

PMCLOG01.01EN