Age PERSONAL INFORMATION

Weight Height Date of next

Date of Visit In
kg cm Visit Child’s Name Sex
Months
Birth Date Type of Delivery Place of Delivery

Birth Weight Birth Length Newborn Screening

Mother’s Name Educational Level

Father’s Name Educational Level

Address:

Contact No.:

SCHEDULE OF IMMUNIZATION
At 6 10 14 9
Vaccine 1 year
birth weeks weeks weeks months
BCG
Bacillus Calmette–Guérin

Hepatitis B
Pentavalent
DPT, Hep-B, Hib
OPV
Oral Polio Vaccine
PCV
Pneumococcal conjugate vaccine

Rotavirus Vaccine
IPV
Inactivated Polio Vaccine
AMV
Measles
MMR
Measles, Mumps, Rubella
OTHERS

EXPANDED PROGRAM ON IMMUNIZATION

EXPANDED PROGRAM ON IMMUNIZATION
 PERSONAL INFORMATION Child’s Name Sex

Child’s Name Sex Birth Date Type of Delivery Place of Delivery

Birth Date Type of Delivery Place of Delivery Birth Weight Birth Length Newborn Screening

Birth Weight Birth Length Newborn Screening Mother’s Name Educational Level

Mother’s Name Educational Level Father’s Name Educational Level

Father’s Name Educational Level Address:

Address: Contact No.:

Contact No.:
SCHEDULE OF IMMUNIZATION

SCHEDULE OF IMMUNIZATION At 6 10 14 9
Vaccine 1 year
birth weeks weeks weeks months
At 6 10 14 9 BCG
Vaccine 1 year
birth weeks weeks weeks months Bacillus Calmette–Guérin
BCG
Bacillus Calmette–Guérin
Hepatitis B

Hepatitis B Pentavalent
DPT, Hep-B, Hib
Pentavalent OPV
DPT, Hep-B, Hib Oral Polio Vaccine
OPV PCV
Oral Polio Vaccine Pneumococcal conjugate vaccine
PCV
Pneumococcal conjugate vaccine
Rotavirus Vaccine

Rotavirus Vaccine IPV

Inactivated Polio Vaccine
IPV AMV
Inactivated Polio Vaccine Measles
AMV MMR
Measles Measles, Mumps, Rubella
MMR OTHERS
Measles, Mumps, Rubella
OTHERS

EXPANDED PROGRAM ON IMMUNIZATION

PERSONAL INFORMATION
 Age Age
Weight Height Date of next Weight Height Date of next
Date of Visit In Date of Visit In
kg cm Visit kg cm Visit
Months Months