CHILD IMMUNIZATION RECORD

CHILD’S NAME: ____________________ MOTHER’S NAME: ____________________

DATE OF BIRTH: ___________________ FATHER’S NAME: ____________________

PLACE OF BIRTH: __________________ WEIGHT: __________ HEIGHT: __________

TEMP.___________ PULSE: __________ RR: __________ SEX: ______________

VACCINE DOSES DATE OF IMMUNIZATION REMARKS

BCG 1 COMPLETED
07/05/14
(at birth)
HEPATITIS B 1 COMPLETED
07/05/14
(at birth)
PENTAVALENT 3 COMPLETED
VACCINE(DPT,HEP.B,HIB) 08/16/14 09/13/14 10/11/14
(1 ½,21/2,3 ½ months)
3 COMPLETED
08/16/14 09/13/14 10/11/14
ORAL POLIO VACCINE (OPV) (1 ½,21/2,3 ½ months)
1 COMPLETED
10/11/14
INACTIVATED POLIO VACCINE (IPV) 3 ½ months
PNEUMOCOCCAL CONJUGATE 3 COMPLETED
VACCINE (PCV) 08/16/14 09/13/14 10/11/14
(1 ½,21/2,3 ½ months)
MEASLES, MUMPS,RUBELLA(MMR) 2 COMPLETED
04/05/15 07/05/15
(9months & 1 year)