Immunization Record
"Click" on the sheet below and go to the borrower's print function.
Take this sheet to your physician's office and ask your provider to fill it out.
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Immunization Record
"Click" on the sheet below and go to the borrower's print function. Take this sheet to your physician's office and ask your provider to fill it out. |
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Date
|
Age
|
Immunization
|
Provider Signature
|
| 1-2 months | HepB | ||
| 2 months | DTP, OPV, Hib | ||
| 4 months | DTP, OPV, Hib, HepB | ||
| 6 months | DTP, OPV, Hib, HepB | ||
| 15 months | DTP, OPV, MMR | ||
| 18 months | Hib | ||
| 4-6 years | DTP, OPV, MMR | ||
| 14-16 years | TD | ||
| 25 | TD | ||
| 34 | TD | ||
| 42 | TD | ||
| 50 | TD | ||
| 59+ | TD | ||
| 60+ | flu | ||
| 60+ or lung problems | Pneumococcus | ||
| 68+ | TD | ||
| Yellow fever | |||
| Yellow fever | |||
| Hepatitis A | |||
| Hepatitis A | |||
| Hepatitis B | |||
| Hepatitis B | |||
| Japanese Encephalitis | |||
| Typhoid | |||
| Typhoid | |||