Immunization Record

© 2010-2014 Vertex42 LLC

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

Date Given Administered By Next Dose Date Given Administered By Next Dose
Vaccine Type (m/d/yy) (clinic, doctor, etc) Date Vaccine Type (m/d/yy) (clinic, doctor, etc) Date
Hepatitis B Hepatitis A
(HepB, Hib-HepB, HepA- (HepA, HepA-HepB)
HepB, DTaP-HepB-IPV)

Diptheria, Tetanus, Meningococcal

Pertussis (MCV4, MPSV4)
(DTaP, DTP, DT, Td, Tdap, Human papillomavirus
DTaP-HepB-IPV, DTaP-
IPV/Hib, DTaP-IPV, (HPV4, HPV2)
DTaP/Hib)
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) Immunization Record Template © 2010-2014 Vertex42 LLC.
(VAR, MMRV)
See Vertex42.com for additional Schedules and Templates.

https://www.vertex42.com/ExcelTemplates/immunization-schedule.html
Immunization Record
By Vertex42.com
https://www.vertex42.com/ExcelTemplates/immunization-schedule.html

© 2010-2014 Vertex42 LLC

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