Shanghai Immunization Record
Name of Child: Sex: Male Birth date: Weight of birth: Kgs
Father: HBsAg: (-)
Mother: HBsAb (-) HBsAg: (-) HBeAb (-) HBeAg: (-) HBcAb (-)
Name of Mother(Father)’s company: Tel:
Current Address:
Residencial Address: Tel:
Current School: Class: Tel: _______________
|
Name of Vaccine |
date |
Lot No. |
Signature |
Name |
date |
Lot No. |
Signature |
|
BCG |
2001.2.20 |
991164 |
|
MV |
2001.10.30 2008.02.27 |
0012084
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HBV |
2001.2.18 2001.3.23 2001.8.20 |
200080217 99103-12 200100108 |
|
Encephalitis B Vaccine |
2002.2.26 2002.3.12 2003.2.19 2007.2.27 |
001004-5 001004-5 2001100103 200605005-7 |
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TOPV |
2001.4.18 2001.5.22 2001.6.22 2002.8.26 2005.3.11 |
000901-01 000903-01 000905-09 2001081002 2004070922 |
|
Meningococcus A Vaccine |
2004.12.5 2007.11.8 2012.12.5 |
20040815-1 2006120104 201112191-2 |
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DPT |
2001.5.22 2001.6.22 2001.7.24 2002.8.26 |
000604-5 001003-3 001003-3 2001120405 |
|
TD |
2007.2.27 |
2005120106 |
|
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MMR |
2003.3.20 2005.3.11 2010.9.16 |
MMR44A42B F0396 2009120101 |
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Varicella Vaccine |
2002.5.20 2014.11.12 |
200202001 201202009-1 |
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Influenza Vaccine |
2010.1.5 |
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Contraindication |
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Allergy History |
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No |
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No |
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Record of Abnormal Reaction |
No |
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