Transcription of Date given Healthcare professional Date next
1 LIFETIME IMMUNIZATION RECORD. Always carry this record with you and have your Healthcare professional or clinic keep it up to date . Last name First name Birthdate: . (mo.) (day) (yr.) Patient Number: Printed by Immunization Action Coalition, Saint Paul, MN. Medical notes ( , allergies, vaccine reactions): Healthcare provider: List the mo/day/yr for each vaccination given . Record the generic abbreviation ( , PCV7, DTaP-IPV/Hib), not the trade name. For com- bination vaccines, fill in a row for each separate antigen in the combination.
2 Item #R2004 (4/09). date next dose due To learn more about vaccines, visit and Healthcare professional or clinic date given mo/day/yr Type of vaccine (HepB, Hib-HepB, DTaP-HepB-IPV, DTaP-HepB-IPV, (DTaP, DTP, DT, Diphtheria, Vaccine B. DTaP-IPV/Hib, Pertussis HepA-HepB). Hepatitis Tetanus, DTaP-IPV, DTaP/Hib). Td, Tdap, Vaccine Type of date given Healthcare professional date next (mo.) (day) (yr.) vaccine mo/day/yr or clinic dose due Last name First name Birthdate Measles, Mumps, Rubella (MMR, Vaccine Type of date given Healthcare professional date next MMRV).
3 Vaccine mo/day/yr or clinic dose due Varicella (VAR, MMRV). H. influenzae type b Hepatitis A, (Hib, Hib-HepB, (HepA, HepA-HepB). DTaP-IPV/Hib, DTaP/Hib) If combo Polio (IPV, OPV, Meningococcal DTaP-HepB-IPV, (MCV4, MPSV4). DTaP-IPV/Hib, DTaP-IPV) Human papillomavirus (HPV4, HPV2). Pneumococcal (PCV7, PCV13, Zoster PPSV23). Influenza (TIV, LAIV). Rotavirus Other (RV5 [RotaTeq]. RV1 [Rotarix], Other RV [unknown]) Get vaccinated against influenza each year to protect yourself and others around you.
