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1 VACCINATION RECORD
2 Vaccination, the best protection This booklet is an important document. It is the only record of all the vaccines you have received. You will need it all your life, so keep it in a safe place and keep it up to date. Take it with you to each medical appointment. For optimal protection, it is important to follow the regular vaccination schedule. Make an appointment at the recommended ages to avoid delays.
3 IDENTIFICATION Family name: Given name: of birth: YEAR / MONTH / DAY Sex: Male Female Health insurance number: Mother s family name: Father s family name: Current telephone number: (in case booklet is lost) Mother s given name: Father s given name: (USE PENCIL AND CORRECT AS NEEDED) 1
4 Table of content 2 Birth Growth... 4 Medical information related to vaccination... 6 Regular vaccination schedule... 8 Diphtheria (d or D) - Tetanus (T) - Pertussis (whooping cough) (ap or ap) - Hepatitis B (HB) - Poliomyelitis (IPV) - Hæmophilus influenzæ type b infections (Hib).10 Rotavirus gastroenteritis Pneumococcal infections Measles (M) - Mumps (M) - Rubella (German Measles) (R) - Chicken pox (varicella) (Var) Meningococcal infections Hepatitis B Human Papillomavirus (HPV) Hepatitis A and hepatitis B (combined vaccine) Hepatitis A Flu Tuberculine Skin Test (TST) Tuberculosis Rabies Typhoid Japanese encephalitis Other vaccines Immunoglobulins Yellow fever... 32
5 BIRTH Place of birth (locality): Time: Name of institution: Length of pregnancy: Type of delivery: vaginal cæserean section Birth weight: /g Blood group: Apgar score: Cranial circumference: /cm Rh factor: Length: /cm 3
6 GROWTH (observations by health care professional) 4 Age Weight/percentile (in g or kg) Length/percentile (in cm) Cranial circumference (in cm)
7 5
8 To be completed by the person administrating the vaccines Medical information related to vaccination (e.g. anaphylactic allergy, side effects following vaccination) 6
9 7
10 Regular vaccination schedule (as of September 1 st, 2016) Certain vaccines are recommanded for everyone. They are part of the regular vaccination schedule. 8 Vaccine protecting against: At 2 months At 4 months At 6 months At 12 months At 18 months Between 4 and 6 Elementary 4 Secondary 3 After 60 Diphtheriatetanus-whooping cough-hepatitis B- polio-hib P P P (without hepatitis B) Pneumococcus P P P Rotavirus P P P P (65 and over) Flu (fall/winter) P* P Meningococcus C P P * At the age of 6 months or as soon as the vaccine is available (fall/winter), then each year until the age of 2.
11 Regular vaccination schedule (continued) (as of September 1 st, 2016) Vaccine protecting against: At 2 months At 4 months At 6 months At 12 months At 18 months Between 4 and 6 Elementary 4 Secondary 3 After 60 Measlesmumps-rubella Chicken pox P P Diphtheriatetanuswhooping coughpolio* P Hepatitis B (the vaccine used protects also against hepatitis A) Human papillomavirus * A dose of Tdap vaccine is also indicated for all adults. Thereafter, a booster dose of diphteria and tetanus is needed every 10 years. Other vaccinations may be recommended for reasons of health, work, activities or travel. P P P P P (without polio) 9
12 Diphtheria (d or D) - Tetanus (T) - Pertussis (whooping cough) (ap or ap) - Hepatitis B (HB)- Poliomyelitis (IPV) - Hæmophilus influenzæ type b infections (Hib) 10 Name of vaccine (print)
13 11
14 Rotavirus gastroenteritis 12 Name of vaccine (print)
15 Pneumococcal infections Name of vaccine (print) 13
16 Measles (M) - Mumps (M) - Rubella (German Measles) (R) - Chicken pox (varicella) (Var) 14 Name of vaccine (print)
17 Meningococcal infections Name of vaccine (print) 15
18 Hepatitis B 16 Name of vaccine (print) Human Papillomavirus (HPV) Name of vaccine (print)
19 Hepatitis A and hepatitis B (combined vaccine) Name of vaccine (print) Hepatitis A Name of vaccine (print) 17
20 Flu 18 Name of vaccine (print)
21 19
22 Flu 20 Name of vaccine (print)
23 21
24 Tuberculine Skin Test (TST) 22 of reading Reaction (in mm) of reading Reaction (in mm)
25 of reading Reaction (in mm) of reading Reaction (in mm) 23
26 Tuberculosis 24 Name of vaccine (print) Rabies Name of vaccine (print)
27 25
28 Typhoid Name of vaccine (print) 26
29 Japanese encephalitis Name of vaccine (print) 27
30 Other vaccines Name of vaccine (print) 28 Vaccine against: Vaccine against: Vaccine against:
31 Vaccine against: Vaccine against: Vaccine against: Vaccine against: 29
32 Other vaccines Name of vaccine (print) 30 Vaccine against: Vaccine against: Vaccine against:
33 Immunoglobulins Name of vaccine (print) Immunoglobulins against: Immunoglobulins against: Immunoglobulins against: 31
34 Yellow fever 32 Staple International Certificate of Vaccination or Prophylaxis here
35
36 KEEP AND TAKE WITH YOU to each medical appointment A Gouvernement du Québec, 2016
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