Blank Immunization Record Card - Free Download
4.1,
4302
votes
Please vote for this template if it helps you.
RETAIN THIS DOCUMENT — CONSERVE ESTE DOCUMENTO
TB SKIN TESTS* Pruebas de la Tuberculosis
Type** Date given Given by Date read Read by mm/indur Impression
* A chest x-ray may be indicated if skin test is positive.
** If required for school entry, must be Mantoux unless exception granted by local health department.
CHEST X-RAY Film date: ____/____/____ Interpretation:
normal abnormal
[Radiografiá] Person is free of communicable tuberculosis
yes no
(Necessary if
skin test positive.)
Signature/Agency: __________________________________________________
Name
nombre
Birthdate
fecha de nacimiento
Sex
sexo
Allergies
alergias
IMMUNIZATION RECORD
Comprobante de Inmunización
Vaccine Reactions
reacciones a la vacuna
VACCINE
vacuna
DATE
GIVEN
fecha de
vacunación
DOCTOR OFFICE OR CLINIC
médico o clínica
NEXT
DOSE DUE
próxima
vacuna
VACCINE
vacuna
DATE
GIVEN
fecha de
vacunación
DOCTOR OFFICE OR CLINIC
médico o clínica
NEXT
DOSE DUE
próxima
vacuna
Parents: Your child must meet California’s immunization requirements to be enrolled in
school and child care. Keep this Record as proof of immunization.
Padres: Su niño debe cumplir con los requisitos de vacunas para asistir a la escuela y a la
guardería. Mantenga este Comprobante: lo necesitará.
DT/Td
= Diphtheria, tetanus [difteria, tétano]
DTaP/Tdap = Diphtheria, tetanus, and pertussis (whooping cough) [difteria, tétano, y tos ferina]
DTP = Diphtheria, tetanus, pertussis (whooping cough) [difteria, tétano, y tos ferina]
HEP A = Hepatitis A
HEP B = Hepatitis B
HIB = Hib meningitis ( Haemophilus influenzae type b) [meningitis Hib]
HPV = Human papillomavirus [virus del papiloma humano]
INFV = Influenza [la gripe]
MCV = Meningococcal conjugate vaccine [vacuna meningocócia conjugada]
MMR = Measles, mumps, rubella [sarampión, paperas y rubéola (sarampión alemán)]
MPV = Meningococcal polysaccharide vaccine [vacuna meningocócia polisacárida]
PNEUMO = Pneumococcal vaccine [neumocócica]
POLIO = Poliomyelitis [poliomielitis]
RV = Rotavirus [rotavirus]
VZV = Varicella (chickenpox) [varicela]
PM 298 F2 (8/08) IMM-75LK
C
M
Y
CM
MY
CY
CMY
K
PM-298F2-IMM-75LK(1-07).ai 4/12/07 9:20:23 AM
Registry ID Number
