| Immunization Record |
| LAST NAME | | FIRST NAME | | M.I. | | BIRTHDATE (mm/dd/yy) |
| | | | | [42] |
| MEDICAL NOTES (allergies, vaccine reactions, etc.) | | | | | | INSTRUCTIONS |
| | | | | | | Record the Type (HepB) and the Date (m/d/yy) for each vaccination given. For combination vaccines (like Hib-HepB), complete a row under each separate antigen in the combination. Take a copy of your immunization record with you when you visit a healthcare professional. Have them assist you in completing the form. For information about the vaccines and recommended immunization schedules, see the Center for Disease Control and Prevention website at http://www.cdc.gov/vaccines |
| Vaccine | Type | Date Given (m/d/yy) | Administered By
(clinic, doctor, etc) | Next Dose Date | | Vaccine | Type | Date Given (m/d/yy) | Administered By
(clinic, doctor, etc) | Next Dose Date |
| Hepatitis B | | | | | | Hepatitis A |
| (HepB, Hib-HepB, HepA-HepB, DTaP-HepB-IPV) | | | | | | (HepA, HepA-HepB) |
| Diptheria, Tetanus, Pertussis | | | | | | Meningococcal |
| | | | | | | (MCV4, MPSV4) |
| (DTaP, DTP, DT, Td, Tdap, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV, DTaP/Hib) | | | | | | Human papillomavirus |
| | | | | | | (HPV4, HPV2) |
| | | | | | | Zoster (shingles) |
| boosters |
| | | | | | | Influenza (yearly) |
| | | | | | | (TIV, LAIV) |
| Haemophilus influenzae type b |
| (Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib) |
| Pneumococcal |
| (PCV7, PCV13, PPSV23) |
| | | | | | | Other |
| Polio |
| (IPV, OPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV) |
| Rotavirus |
| (RV1, RV5, RV [unknown]) |
| Measles, Mumps, & | | | | | | [42] |
| Rubella (MMR, MMRV) |
| Varicella (chickenpox) |
| (VAR, MMRV) |
kprnechhckin
unit_6-immunization-record.xlsx
