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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