WEST VIRGINIA
Immunization Record
Official Document
DEPARTMENT OF COMMUNITY HEALTH
STATE OF WEST VIRIGINIA
Official State of West Virginia Immunization Record
ILIR ID#: 8865704932
Name: Allston Robinson
Gender: M Immunization Provider
Responsible Party: Joseph Rutherford BERKELEY MEDICAL CENTER
Address: 683 Aztec Dr Age: 12 Years, 4 Months 2500 HOSPITAL DR
City,State,Zip: Martinsburg, WV 25405 DOB: 01/26/2003 MARTINSBURG, WV 25401
Telephone: Patient ID#: 740364772 TEL:304-264-1000.
As of: May 26, 2015
Provider: Assessment indicates that vaccinations are up to date or should not be administered today due to
medical contraindications.
History of Vaccinations Given by Series
Vaccine Series Dose#1 Dose#2 Dose#3 Dose#4 Dose#5 Dose#6 Dose#7
DTP/DTaP/DT/Td/Tdap 03/17/2003 05/10/2003 09/22/2003
Polio 01/26/2003 03/17/2003 09/22/2003
MMR 10/15/2003 07/02/2004
Hib 03/17/2003
Hepatitis B 09/22/2003 07/02/2004
Pneumococcal Conjugate 03/21/2003
Pneumococcal 03/21/2005
Polysaccharide
Tuberculosis 08/02/2004 03/09/2005
Hepatitis A 08/02/2004 04/15/2005
Seasonal Influenza 06/17/2004 01/22/2005 03/01/2005 03/10/2006 08/08/2007
Various Immune Globulins 04/12/2004
Other 03/15/2006
1997 H1N1 Influenza
Immunization Status and Shots Needed
Vaccine Next Dose Due Accelerated Due Date Recommended Date Overdue Date
DTaP Complete
Polio Complete
MMR Complete
Hepatitis B Immune
Varicella Complete
Hepatitis A Complete
Seasonal Influenza Complete
Signature:____________________________ 26
Date:_____/_____/___
05 2015
