Transcription of Child & Teen Immunization Record card
1 (mo.) (day) (yr.)Printed by Immunization Action Coalition, Saint Paul, MN & TEEN Immunization RECORDA lways carry this Record with you and have yourhealthcare professional or clinic keep it up to date. Last name First name Birthdate: Patient Number: To learn more about vaccines, visit and (Hep B)(DTaP,DT, Td,Tdap)Medical notes ( , allergies, vaccine reactions):Healthcare provider: List the mo/day/yr for each vaccination given. Record thegeneric abbreviation ( , PCV, DTaP-HepB-IPV), not the trade name. For com-bination vaccines, fill in a row for each separate antigen in the combination. Type ofDate given Health professional Date next vaccine mo/day/yr or clinic dose due Hepatitis B Diphtheria, OtherTe t a n u s ,Pertussis(DTaP, DTP, DT,Td, Tdap,DTaP-HepB-IPV,DTaP-Hib)(HepB, Hib-HepB,HepA-HepB)Item #R2003 (1/07)Vaccine Measles, Mumps, Varicella Hepatitis A Mening.
2 (MCV, MPSV) Human Influenza Haemophilus Polio (IPV, OPV, Pneumococcal Rotavirusinfluenzaetype b (Hib, Hib-HepB, DTaP-Hib)(PCV, PPV)Last name First name BirthdateTo protect yourself and others around you from influenza, get vaccinated every (MMR,(Var, MMRV)(HepA, HepA-HepB)(HPV)(Rota)If comboMMRV)DTaP-HepB-IPV) Type ofDate given Health professional Date next vaccine mo/day/yr or clinic dose due Type ofDate given Health professional Date next vaccine mo/day/yr or clinic dose dueVaccineVaccine(TIV, LAIV)
