Transcription of Child and Teen Immunization Record
1 Vaccine Type of Date given Healthcare professional Date next vaccine mo/day/yr or clinic name dose due Hepatitis B(HepB, Hib-HepB, DTaP-HepB-IPV, HepA-HepB)(mo.) (day) (yr.) Child and Teen Immunization RecordAlways carry this Record with you and have your healthcare professional or clinic keep it up to date.
2 Last name First name Birthdate: Patient Number: Immunization Action Coalition Saint Paul, Minn. To order additional Record cards, visit Medical notes ( , allergies, vaccine reactions):Healthcare provider: List the mo/day/yr for each vaccination given. Record the generic abbreviation ( , PCV13, DTaP-HepB-IPV) or the trade name. For combination vaccines, fill in a row for each separate antigen in the #R2003 (8/16)Diphtheria,Tetanus,Pertussis(whoop ing cough)(DTaP, DTP, DT, Td, Tdap, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV, DTaP/Hib)To learn more about vaccines, visit and Influenza (IIV, LAIV)Hepatitis A(HepA, HepA-HepB) Human papillomavirus(HPV2, HPV4, HPV9)Measles, Mumps, Rubella (MMR, MMRV)Varicella (chickenpox) (Var, MMRV)If combinationGet vaccinated against influenza each year to protect yourself and others around you.
3 H. influenzaetype b (Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib, Hib-MenCY)Pneumococcal (PCV7, PCV13, PPSV23)Polio (IPV, OPV, DTaP-HepB-IPV, DTaP-IPV/Hib,DTaP-IPV) Rotavirus(RV5 [RotaTeq], RV1 [Rotarix],RV [unknown])Last name First name BirthdateMeningococcal(MenACWY [MCV4], MenB, MPSV4, Hib-MenCY)
4 Vaccine Type of Date given Healthcare professional Date next vaccine mo/day/yr or clinic name dose due Vaccine Type of Date given Healthcare professional Date next vaccine mo/day/yr or clinic name dose due (mo.) (day) (yr.) Other
