Child and Teen Immunization Record Card - Free Download
4.4,
4219
votes
Please vote for this template if it helps you.
Vaccine
Type of Date given Healthcare professional Date next
vaccine mo/day/yr or clinic dose due
Hepatitis B
(HepB, Hib-HepB,
DTaP-HepB-IPV,
HepA-HepB)
(mo.) (day) (yr.)
CHILD & TEEN IMMUNIZATION RECORD
Always carry this record with you and have your
healthcare professional or clinic keep it up to date.
Last name First name M.I.
Birthdate:
Patient
Number:
–
–
Printed by Immunization Action Coalition, Saint Paul, MN
www.immunize.org • www.vaccineinformation.org
Medical notes (e.g., allergies, vaccine reactions):
Healthcare provider: List the mo/day/yr for each vaccination given. Record the
generic abbreviation (e.g., PCV13, DTaP-HepB-IPV) or the trade name. For
combination vaccines, fill in a row for each separate antigen in the combination.
Item #R2003 (9/10)
Diphtheria,
Tetanus,
Pertussis
(DTaP, DTP, DT,
Td, Tdap,
DTaP-HepB-IPV,
DTaP-IPV/Hib,
DTaP-IPV,
DTaP/Hib)
Other
To learn more about vaccines, visit www.immunize.org or www.vaccineinformation.org
