Use this chart or an official immunization card to keep track of your child's immunizations. Select for more information on immunizations. Significant reactions should be recorded and reported to your health care provider immediately.
| Type of Immunization | Enter Dates, Name/Initials of Provider and Other Information Below | |||||
|---|---|---|---|---|---|---|
| Hepatitis B | Dates Received Provider/Clinic |
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| Diphtheria Tetanus, Pertussis (DTaP) |
Dates Received Provider/Clinic |
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| Tetanus and Diphtheria |
Dates Received Provider/Clinic |
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| Haemophilus Influenzae type b |
Dates Received Provider/Clinic |
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| Poliovirus | Dates Received Provider/Clinic |
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| Measels, Mumps, Rubella |
Dates Received Provider/Clinic |
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| Chicken Pox (Varicella) |
Dates Received Provider/Clinic |
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| Pneumococcal Disease (PCV) |
Dates Received Provider/Clinic |
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| Hepatitis A | Dates Received Provider/Clinic |
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| Influenza | Dates Received Provider/Clinic |
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The Pocket Guide to Good Health for Children