Tuberculosis (TB) skin test result

Date given Date read Induration Comments Provider or Adult Immunization Record
(y/m/d) (y/m/d) size (mm) clinic
Keep your immunizations up to date.
It’s one of the best things you can do to protect your health.

Name

Date of Birth

Personal Health Number

This is a permanent record.

Keep it in a safe place.

For information about immunization,

speak to your health care provider or
visit www.immunizebc.ca.

A free immunization tracking app.

www.canimmunize.ca.

01/20
 Adult Immunization Record
Vaccine Type of Date given Provider or Date next Vaccine Type of Date given Provider or Date next
vaccine (y/m/d) clinic dose due vaccine (y/m/d) clinic dose due
(y/m/d) (y/m/d)
Hepatitis A Tetanus,
(HepA, HepA-HepB) Diphtheria,
Pertussis
(whooping cough)
(Td, Tdap)
Hepatitis B
(HepB, HepA-HepB)

Zoster
(shingles)
Human Papillomavirus
(HPV9, HPV4, HPV2) Other (e.g. travel
vaccines)

Measles, Mumps,
Rubella (MMR)

Meningococcal
(Men-C, MCV4)

Pneumococcal Influenza (flu) y/m/d y/m/d y/m/d y/m/d

(PPV23, PCV13) (TIIV, QIIV, LAIV,
HD TIIV) y/m/d y/m/d y/m/d y/m/d

y/m/d y/m/d y/m/d y/m/d

Recommended yearly
Polio y/m/d y/m/d y/m/d y/m/d
(IPV)
y/m/d y/m/d y/m/d y/m/d

* Tuberculosis skin test result chart is on back page

Varicella
(chickenpox)