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Health Surveillance Referral Information (3932314)
Summary Immunisation Assessment Notes History Protocols

Appointment

Show form for the following appointment

Employee Details

ERN

3213574

First Name

Jane

Surname

Russell

Date of Birth

03/05/1960

Job Title

Staff Member

Referring Manager

Graham Hannah

Assessment Details

Type of Assessment

MMR 2nd Vaccination

Assessment Date

23/04/2024

Client Name

Birmingham and Solihull Mental Health NHS Foundation Trust

Clinician Name

Juliet Davis

Linked Referral

Supporting Documents

N/A

Additional Services

Service Type Service Due Due Date Traffic Light Action
Immunisation BCG Vaccination Select
Immunisation HEP B Vaccination Select
Blood Test HEP B Surface Antigen Select
Blood Test Measles Immunity Select
Blood Test Rubella Immunity Select
Blood Test Varicella Serology Immunity Select
Blood Test HEP C Serology Antibodies ABS Select
Blood Test HIV1 & HIV2 Blood Test Select
Blood Test HEP B Antibody Select
Blood Test Group A Streptoccus (Swab) Select
Blood Test Hepatitis C PCR Select
Immunisation Hep B Yr1 Booster Select
Immunisation Hep B Yr5 Booster Select
Immunisation MMR 1st Vaccination Select
Immunisation Stage 1 Hep B Vaccination Select
Immunisation Stage 2 Hep B Vaccination Select
Immunisation Stage 3 Hep B Vaccination Select
Immunisation Varicella 1st Vaccination Select
Immunisation Varicella 2nd Vaccination Select
Immunisation Hep B Vaccination booster Select
Blood Test IGRA Blood Test Select
Blood Test Hep B Core ABS Serology Select
Blood Test D&A Random Sent to Lab Select
Immunisation Imms Status Complete Select
Immunisation Imms Status Interim (BCG/Mantoux Outstanding) Select
Immunisation Imms Status Interim (other bloods or imunisation required) Select

Assessment

Immunisation Screening

Tooltip Customer Order Reference
1. Are you well today?
*
*
2. Do you have allergies?
*
*
3. Have you ever had a serious reaction after receiving a vaccination?
*
*
4. Do you have any long term health problems?
*
*
5. Have you got any condition affecting the immune system or are you taking any medication which affects the immune system?
*
*
6. During the past year, have you received a transfusion of blood or blood products or been given immunoglobulin?
*
*
7. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
*
8. Have you received any other vaccines in the last 4 weeks or BCG in the last 3 months? (NB: If BCG given in the last 3 months, this vaccine must be given in the opposite arm)
*
*
"I consent to PAM, who I have been advised is the occupational health provider performing the immunisations. I also consent to Anaphylaxis treatment in the event of an adverse reaction to the vaccines. The details above are true and accurate statements."
*

Assessment Notes

Vaccination Vacc Date Dosage Batch Number Expiry Date Recall Weeks Completed
MMR 2nd Vaccination
*
* *
*
* *

Clinical Notes

Anaphylaxis Administered
*

Did not Attend

*

Vaccination not administered

*

Referral Status
*

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