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Example of Immunization Record Template


Immunization Record

 

 

Name

 
Date of Birth

 
Medical Notes

Vaccine Date Administered by Location Next Dosage Reaction Notes
Hepatitis B          
         
         
         
         
Diphtheria, Tetanus, Pertussis          
         
         
         
         
H. Influenza type b          
         
         
         
         
Inactivated Poliovirus          
         
         
         
         
Pneumococcal          
         
         
         
         
Measles, Mumps, Rubella          
         
         
         
         
Varicella (Chickenpox)          
         
         
         
         
         
Hepatitis A          
         
         
         
         
         
Rotavirus          
         
         
         
         
Human Papillomavirus          
         
         
         
         
         
Influenza (yearly vaccine)          
         
         
         
         
         
Other Vaccines          
         
         
         
         
         
         
         


Notes on Immunization Record Example

Use this Immunization Record to keep track of yours or your child's immunizations.

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Download Example Immunization Record Excel Template