Child Health Guide
Immunization Record
Use this chart or an official immunization card to keep track of your child's
immunizations. Be sure to talk with your child's health care provider about possible
reactions and what you should do. Significant reactions should be recorded and reported to
your health care provider immediately.
Child's Name____________________________________________
Type of Immunization Enter Dates, Names, Initials of Provider, and
Other Information Below
Polio (IPV/OPV)
Dates received _________ _________ _________ _________ Provider/clinic _________
_________ _________ _________
Recommended age 2 mo. 4 mo. 6-18 mo. 4-6 yrs.
___________________________________________________________________________
Diphtheria, Tetanus, Pertussis (DTaP/DTP, Td)
Dates received _________ _________ _________ _________ _________ _________
Provider/clinic _________ _________ _________ _________ _________ _________
Recommended age 2 mo. 4 mo. 6 mo. 15-18 mo. 4-6 yrs. 11-16 yrs. DTaP/DTP DTaP/DTP
DTaP/DTP DTaP/DTP DTaP/DTP Td
___________________________________________________________________________
Measles, Mumps, Rubella (MMR)
Dates received _________ _________________ Provider/clinic _________ _________________
Recommended age 12-15 mo. 4-6 or 11-12 yrs.
___________________________________________________________________________
Haemophilus Influenzae (Hib)
Dates received _________ _________ ___________ _________ Provider/clinic _________
_________ ___________ _________
Recommended age 2 mo. 4 mo. 6 mo. 12-15 mo. Not PRP-OMP
___________________________________________________________________________
Hepatitus B (HBV)
Dates received _________ _________ ___________________ Provider/clinic _________
_________ ___________________
Recommended age Birth- 1-4 mo. 6-18 mo. 2 mo.
___________________________________________________________________________
Chickenpox (VZV)
Date received _________ Provider/clinic _________
Recommended age 1-12 yrs.
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