Immunization Record

Jun 17th, 2015
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Adelphi University
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Immunization RecordTo Be Completed From Your Own or Your Physicians Documented RecordsActual Dates of Immunization Are NecessaryLast Name _________________________ First Name ____________________ Middle Initial ______DOB ___/___/_____HEPATITIS B (Three doses of vaccine)Immunization Dose #1 ___/___/_____ Immunization Dose #2 ___/___/_____ Immunization Dose #3 ___/___/_____ HEPATITIS A (Two doses of vaccine 6 months apart)Immunization Dose #1 ___/___/_____ Immunization Dose #2 ___/___/_____MMR (Measles, Mumps, Rubella) (2 doses required)Dose #1 age 12-15 months or later ___/___/_____Dose #2 age 4-6 years or later and at least 4 weeks after first dose___/___/_____TETANUS-DIPTHERIA (Primary series with DtaP or DPT and a booster dose of Tdap or Td every 10 years)Dose #1 ___/___/_____ Dose #2 ___/___/_____ Dose #3 ___/___/_____ Dose #4 ___/___/_____ Dose #5 ___/___/_____ Dose #6 ___/___/_____ Dose #7 ___/___/_____ Dose #8 ___/___/_____ Dose #9 ___/___/_____Dose #10 ___/___/_____Dose #11 ___/___/_____ Dose #12 ___/___/_____ Dose #13 ___/___/_____ Dose #14 ___/___/_____ Dose #15___/___/_____ Dose #16 ___/___/_____ Dose #17___/___/_____ Dose #18 ___/___/_____ Dose #19 ___/___/____ Dose #20 ___/___/_____ Tdap (Boostrix or Adacel) or Td booster dose every 10 yrs. (circle one if known)Booster #1Date ___/___/_____Booster #2Date ___/___/_____ POLIO (Primary se

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