Health Record Immunization Record Page 2
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1
2ORAL POLIOVIRUS VACCINE
DATE
DOSE
PHYSICIAN'S NAME
DATE
DOSE
PHYSICIAN'S NAME
1
3
2
4
INFLUENZA VACCINE
DATE
DOSE
PHYSICIAN'S NAME
DATE
DOSE
PHYSICIAN'S NAME
1
3
2
4
OTHER IMMUNIZATIONS
DATE
DOSE
PHYSICIAN'S NAME
DATE
DOSE
PHYSICIAN'S NAME
1
5
2
6
7
3
8
4
SENSITIVITY TEST (Tuberculin, etc.)
DATE
TYPE
DOSE
ROUTE
RESULTS
PHYSICIAN'S NAME
1
2
3
4
5
REMARKS:
THIS RECORD IS ISSUED IN ACCORDANCE WITH ARTICLE 99, WHO SANITARY REGULATION NO.2
* U.S.GPO:1997-427-590/69093
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Parent category: Medical