BHS-Crossing

INDIVIDUAL TREATMENT RECORD

Activity: National Immunization Program

Name of the
Child:_____________________________________________________Age:__________Sex:________
Date of Birth:_______________Place of Birth:______________________________Health Facility
Yes__No__
Name of the Guardian/Parent(s):____________________________________Contact
No.__________________
Address:_______________________________________________________ BHW
Assigned:___________________

Vaccine Date Given Remarks Vaccine Date Given Remarks

Hepa B PCV 1
BCG PCV 2
OPV 1 PCV 3
OPV 2 IPV
OPV 3 Measles
Penta 1 MMR
Penta 2 Rota 1
Penta 3 Rota 2

 Other Data
- Exclusive Breastfeeding? Yes___No___ (Receives breast milk for 6 mos without any additional food
or drink, not even water but the prescribed vitamins can be given to the child)
 Any Unusual Observations(Care Provider)/ Complaints expressed by the parent/guardian
Date:

BHS-Crossing
INDIVIDUAL TREATMENT RECORD

Activity: National Immunization Program

Name of the
Child:_____________________________________________________Age:__________Sex:________
Date of Birth:_______________Place of Birth:______________________________Health Facility
Yes__No__
Name of the Guardian/Parent(s):____________________________________Contact
No.__________________
Address:_______________________________________________________ BHW
Assigned:___________________

Vaccine Date Given Remarks Vaccine Date Given Remarks

Hepa B PCV 1
BCG PCV 2
OPV 1 PCV 3
OPV 2 IPV
OPV 3 Measles
Penta 1 MMR
Penta 2 Rota 1
Penta 3 Rota 2

 Other Data
 - Exclusive Breastfeeding? Yes___No___ (Receives breast milk for 6 mos without any additional food
or drink, not even water but the prescribed vitamins can be given to the child)
 Any Unusual Observations(Care Provider)/ Complaints expressed by the parent/guardian
Date: