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Vaccination Record

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RECORD


This booklet is an important document. It is the only record<br />

of all the vaccines you have received. You will need it all<br />

your life, so keep it in a safe place and keep it up to date.<br />

Take it with you to each medical appointment.<br />

<strong>Vaccination</strong><br />

provides good protection


identification<br />

Family name : _______________________________________________________________________<br />

Given name : ____________________ Date of birth : ____ /____ /____ Sex : M F<br />

year month day<br />

Health insurance number : _______________________________________________________<br />

Mother’s family name :_______________________ Mother’s given name :_ __________________<br />

Father’s family name :__________________________ Father’s given name :__________________<br />

Current telephone number (in case booklet is lost) :_ _____________________________________<br />

Use pencil and correct as needed.


Table of contents<br />

Birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3<br />

Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-5<br />

Medical information<br />

related to vaccination. . . . . . . . . . . . . . . . . . . . . . . . . .6-7<br />

Regular vaccination schedule . . . . . . . . . . . . . . . . . .8-9<br />

Diphtheria, tetanus, pertussis (whooping cough),<br />

poliomyelitis, Haemophilus influenzae<br />

type b infections. . . . . . . . . . . . . . . . . . . . . . . . . . . 10-11<br />

Rotavirus gastroenteritis . . . . . . . . . . . . . . . . . . . . . . . 12<br />

Pneumococcal infection . . . . . . . . . . . . . . . . . . . . . . . 13<br />

Measles, mumps, rubella (German measles),<br />

chickenpox (varicella) (Var) . . . . . . . . . . . . . . . . . . . . 14<br />

Meningococcal infection. . . . . . . . . . . . . . . . . . . . . . . 15<br />

Hepatitis B and Human Papillomavirus (HPV) . . . . 16<br />

Hepatitis A and hepatitis B . . . . . . . . . . . . . . . . . . . . . 17<br />

Flu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-21<br />

Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22<br />

Tuberculine Skin Test (TST) . . . . . . . . . . . . . . . . 22-23<br />

Rabies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24-25<br />

Typhoid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26<br />

Japanese encephalitis . . . . . . . . . . . . . . . . . . . . . . . . . 27<br />

Other vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-30<br />

Immunoglobulins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31<br />

Yellow fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32<br />

2


Birth<br />

Place of birth (locality) :_________________________________ Time :_ ___________________<br />

Name of institution :_____________________________________________________________<br />

Length of pregnancy :____________________________________________________________<br />

Type of delivery : vaginal caesarean section<br />

Birth weight :___________________ /g Blood group :________ Apgar score :__________________<br />

Cranial<br />

circumference :______________ /cm<br />

Rh factor :__________________________________________<br />

3 Length :_ ________________________________________________________________________ /cm


4<br />

GROWTH (observations by health care professional)<br />

Date (year/month/day) Age Weight/percentile Length/percentile Cranial circum-<br />

(in g or kg) (in cm) ference (in cm)


6<br />

To be completed by the person administering the vaccines<br />

Medical information related to vaccination<br />

(e.g. anaphylactic allergy, side effects following vaccination)


VACCINES<br />

Certain vaccines are recommended for everyone. They are part of the regular vaccination schedule.<br />

Regular vaccination schedule (as of November 1, 2011)<br />

Between 2 and 23 months<br />

At 2, 4, 6 and 18 months At 12 months At 18 months<br />

DTaP-Polio-Hib<br />

PROTECTION AGAINST :<br />

• diphtheria (D)<br />

• tetanus (T)<br />

• pertussis (whooping<br />

cough) (aP)<br />

• poliomyelitis (Polio)<br />

• severe Haemophilus influenzae type b<br />

infections (Hib)<br />

At 2 and 4 months<br />

PNEUMOCOCCAL CONJUGATE<br />

PROTECTION AGAINST :<br />

• serious infections caused by the<br />

pneumococcal germ<br />

rotavirus<br />

PROTECTION AGAINST :<br />

• Rotavirus gastroenteritis<br />

PNEUMOCOCCAL CONJUGATE<br />

PROTECTION AGAINST :<br />

• serious infections caused by the<br />

pneumococcal germ<br />

mEningocoCCUS<br />

PROTECTION AGAINST :<br />

• group C<br />

meningococcal infection<br />

mMR-Var<br />

PROTECTION AGAINST :<br />

• measles (M)<br />

• mumps (M)<br />

• rubella (German measles) (R)<br />

• chickenpox (Var)<br />

mMR<br />

PROTECTION AGAINST :<br />

• measles (M)<br />

• mumps (M)<br />

• rubella (German measles) (R)<br />

Between 6 and 23 months<br />

FLU<br />

During the flu season<br />

PROTECTION AGAINST :<br />

• Flu<br />

8


VACCINES<br />

9<br />

Certain vaccines are recommended for everyone. They are part of the regular vaccination schedule.<br />

Regular vaccination schedule (as of November 1, 2011)<br />

Between 4 and 16 years of age<br />

Between 4 and 6 years of age En 4 th year of elementary school Between 14 and 16 years of age<br />

Tdap-Polio<br />

Hepatitis B<br />

Tdap*<br />

PROTECTION AGAINST :<br />

PROTECTION AGAINST :<br />

PROTECTION AGAINST :<br />

• tetanus (T)<br />

• hepatitis B<br />

• tetanus (T)<br />

• diphtheria (d)<br />

including a protection<br />

against hepatitis A<br />

• pertussis (whooping<br />

• diphtheria (d)<br />

• pertussis (ap)<br />

cough) (ap)<br />

HPV (girls)<br />

• poliomyelitis (Polio)<br />

PROTECTION AGAINST :<br />

• HPV<br />

The annual flu vaccination for those aged 60 or older, and the pneumococcal polysaccharide vaccination at age 65,<br />

are also part of the regular vaccination schedule.<br />

Other vaccinations may be recommended for reasons of health, work, activities or travel.<br />

Subsequently, a booster of Td<br />

vaccine every 10 years thereafter.<br />

* A dose of this vaccine is also indicated<br />

for all adults.<br />

HPV (girls)<br />

PROTECTION AGAINST :<br />

• HPV


Diphtheria (d or D) -Tetanus (T) - Pertussis (whooping cough) (ap or aP) -<br />

Poliomyelitis (Polio) - H. influenzae type b infections (Hib)<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

10


12<br />

Rotavirus gastroenteritis<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.


Pneumococcal infection<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

13


Measles (M) - Mumps (M) - Rubella (German measles) (R) - Chickenpox (varicella) (Var)<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

14


Meningococcal infection<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

15


Hepatitis B<br />

Human Papillomavirus (HPV)<br />

16


Hepatitis A and hepatitis B (combined vaccine)<br />

Hepatitis A<br />

17


Flu<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

18


Flu<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

20


Tuberculosis<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

Tuberculine Skin Test (TST)<br />

Date (year-month-day)<br />

Dose/route of admin. Signature<br />

Date of reading Reaction (in mm) Signature<br />

22


Date (year-month-day)<br />

Dose/route of admin. Signature<br />

Date of reading Reaction (in mm) Signature<br />

Date (year-month-day)<br />

Dose/route of admin. Signature<br />

Date of reading Reaction (in mm) Signature<br />

Date (year-month-day)<br />

Dose/route of admin. Signature<br />

Date of reading Reaction (in mm) Signature<br />

23


Rabies<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

24


Typhoid<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

26


Japanese encephalitis<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

27


Other vaccines<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

Vaccine against :<br />

Vaccine against :<br />

28<br />

Vaccine against :


Vaccine against :<br />

Vaccine against :<br />

Vaccine against :<br />

29


Other vaccines<br />

Date (year-month-day) Name of vaccine Dose/route of Signature<br />

(Print)<br />

admin.<br />

Vaccine against :<br />

Vaccine against :<br />

30<br />

Vaccine against :


Immunoglobulins<br />

Date (year-month-day) Name of product Dose/route of Signature<br />

(Print)<br />

admin.<br />

Immunoglobulins against :<br />

Immunoglobulins against :<br />

31<br />

Immunoglobulins against :


Yellow fever<br />

32


Place international certificate of vaccination or revaccination here.


KEEP AND TAKE<br />

WITH YOU TO EACH<br />

MEDICAL APPOINTMENT.<br />

11-278-11A

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