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Immunization Record Tracker

This document is an immunization record chart containing fields to log a patient's name, date of birth, medical notes, allergies or previous reactions, and a table to record details of administered vaccines including the vaccine name, type, date given, administrator, and next scheduled dose date. The table includes lines for common vaccines such as hepatitis B, diphtheria/tetanus/pertussis, haemophilus influenzae type b, pneumococcal, polio, rotavirus, measles/mumps/rubella, varicella, hepatitis A, meningococcal, human papillomavirus, zoster, and influenza.

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cynthia.maez222
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225 views2 pages

Immunization Record Tracker

This document is an immunization record chart containing fields to log a patient's name, date of birth, medical notes, allergies or previous reactions, and a table to record details of administered vaccines including the vaccine name, type, date given, administrator, and next scheduled dose date. The table includes lines for common vaccines such as hepatitis B, diphtheria/tetanus/pertussis, haemophilus influenzae type b, pneumococcal, polio, rotavirus, measles/mumps/rubella, varicella, hepatitis A, meningococcal, human papillomavirus, zoster, and influenza.

Uploaded by

cynthia.maez222
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Immunization Record Chart

LAST NAME FIRST NAME MIDDLE NAME


[42]
MEDICAL NOTES
Allergies?
Reactions?

Date Given Administered By Next Dose Date


Vaccine Type
(m/d/yy)
Hepatitis B
(HepB, Hib-HepB, HepA-HepB, DTaP-HepB-IPV)

Diptheria, Tetanus, Pertussis

(DTaP, DTP, DT, Td, Tdap, DTaP-HepB-IPV,


DTaP-IPV/Hib, DTaP-IPV, DTaP/Hib)

boosters

Haemophilus influenzae type b

(Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib)

Pneumococcal
(PCV7, PCV13, PPSV23)

Polio
(IPV, OPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV)

Rotavirus
(RV1, RV5, RV [unknown])

Measles, Mumps, &


Rubella (MMR, MMRV)
Varicella (chickenpox)
(VAR, MMRV)
BIRTHDATE (mm/dd/yy)

OTHER

Date Given Administered By Next Dose Date


Vaccine Type
(m/d/yy)
Hepatitis A
(HepA, HepA-HepB)

Meningococcal
(MCV4, MPSV4)

Human papillomavirus
(HPV4, HPV2)

Zoster (shingles)

Influenza (yearly)

[42]

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