Vaccination Record
Vaccination Record
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