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The Blank Immunization Record Card is a very simple immunization record template. This template has two languages which will provide convenience to people whose mother tongue is Spanish. The beginning of this template is the basic personal information. Then the four items, Vaccine, Date Given, Doctor Office or Clinic and Next Dose Due compose the main content of this blank immunization record. You can download this file and fill the specific information in this template. Also, it is free.

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RETAIN THIS DOCUMENT — CONSERVE ESTE DOCUMENTO
TB SKIN TESTS* Pruebas de la Tuberculosis
Type** Date given Given by Date read Read by mm/indur Impression
* A chest x-ray may be indicated if skin test is positive.
** If required for school entry, must be Mantoux unless exception granted by local health department.
CHEST X-RAY Film date: ____/____/____ Interpretation:
normal abnormal
[Radiografiá] Person is free of communicable tuberculosis
yes no
(Necessary if
skin test positive.)
Signature/Agency: __________________________________________________
Name
nombre
Birthdate
fecha de nacimiento
Sex
sexo
Allergies
alergias
IMMUNIZATION RECORD
Comprobante de Inmunización
Vaccine Reactions
reacciones a la vacuna
VACCINE
vacuna
DATE
GIVEN
fecha de
vacunación
DOCTOR OFFICE OR CLINIC
médico o clínica
NEXT
DOSE DUE
próxima
vacuna
VACCINE
vacuna
DATE
GIVEN
fecha de
vacunación
DOCTOR OFFICE OR CLINIC
médico o clínica
NEXT
DOSE DUE
próxima
vacuna
Parents: Your child must meet California’s immunization requirements to be enrolled in
school and child care. Keep this Record as proof of immunization.
Padres: Su niño debe cumplir con los requisitos de vacunas para asistir a la escuela y a la
guardería. Mantenga este Comprobante: lo necesitará.
DT/Td
= Diphtheria, tetanus [difteria, tétano]
DTaP/Tdap = Diphtheria, tetanus, and pertussis (whooping cough) [difteria, tétano, y tos ferina]
DTP = Diphtheria, tetanus, pertussis (whooping cough) [difteria, tétano, y tos ferina]
HEP A = Hepatitis A
HEP B = Hepatitis B
HIB = Hib meningitis ( Haemophilus influenzae type b) [meningitis Hib]
HPV = Human papillomavirus [virus del papiloma humano]
INFV = Influenza [la gripe]
MCV = Meningococcal conjugate vaccine [vacuna meningocócia conjugada]
MMR = Measles, mumps, rubella [sarampión, paperas y rubéola (sarampión alemán)]
MPV = Meningococcal polysaccharide vaccine [vacuna meningocócia polisacárida]
PNEUMO = Pneumococcal vaccine [neumocócica]
POLIO = Poliomyelitis [poliomielitis]
RV = Rotavirus [rotavirus]
VZV = Varicella (chickenpox) [varicela]
PM 298 F2 (8/08) IMM-75LK
C
M
Y
CM
MY
CY
CMY
K
PM-298F2-IMM-75LK(1-07).ai 4/12/07 9:20:23 AM
Registry ID Number
Blank Immunization Record Card
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