Immunization History Record
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1
2IMMUNIZATION HISTORY RECORD
Patient: _________________________________________ Birthdate: _______________________
Immunization
Date
Dose
Site
Manufacturer and
Initial
Comments/
Lot Number
Reactions
Diphtheria
Tetanus
Pertussis
(note if DT)
Tetanus
Diphtheria
(adult Td)
Polio
Measles, Mumps,
Rubella
Measles
Haemophilus
influenzae b
Hepatitis B
Gamma Globulin
Tetanus
Toxoid
Flu
Type
Atherton Allergists • 3301 El Camino Real, Suite 101 • Atherton, CA 94027 •
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