Measles Vitamin A Supplementation Record
Record and track vitamin A supplementation details for patients receiving measles care.
Patient Full Name
*
First Name
Last Name
Patient ID or Medical Record Number
*
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Measles Diagnosis/Status
*
Confirmed case
Suspected case
Contact/Exposure
Other
Date of Supplementation Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vitamin A Dose Given
*
Please Select
50,000 IU (infants 0–5 months)
100,000 IU (infants 6–11 months)
200,000 IU (children 12 months and older)
Other
Route of Administration
*
Oral
Intramuscular (IM)
Other
Provider/Facility Name
*
History of Prior Vitamin A Doses for This Illness Episode
*
First dose
Second dose
Third dose
Unknown
Observations or Adverse Reactions Noted
Follow-Up Required
*
Yes
No
Record Notes / Additional Comments
Submit Record
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