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Name:

Date of Birth:
Social Security:
Address:
Parents Name:

Patient ID

18664 01319

Calendar

Appointment Reminders
6 weeks

9-12 months

14 weeks

12-18 months

Birth

10 weeks

January
S

March

February

TH

TH

F
1

S
2

April

TH

TH

10

11

12

10

11

12

13

13

14

15

16

17

18

19

10

11

12

13

14

15

16

10

11

12

13

14

15

16

14

15

16

17

18

19

20

25

26

22

23

24

25

26

27

F
2

S
3

20

21

22

23

24

27

28

29

30

31

17

18

19

20

21

24

25

26

27

28

17

18

19

20

21

22

23

21

22

23

24

25

26

27

28

29

30

28

29

30

TH

31

June

May
S

TH

10

11

12

13

14

15

16

17

18
25

19

20

21

22

23

24

26

27

28

29

30

31

TH

2
9
16
23
30

3
10
17
24

September

T
4
11
18
25

W TH
5
12
19
26

6
13
20
27

July

7
14
21
28

S
1
8
15
22
29

21

22

28

29

TH

10

11

12

13

10

15

16

17

18

19

20

11

12

13

14

15

16

17

23

24

25

26

27

30

31

TH

10

11

12

13

14

10

11

12

16

17

18

19

20

21

13

14

15

16

17

18

19

10

11

12

13

14

15

16

22

23

24

25

26

27

28

25

26

29

30

21

22

23

24

28

29

30

31

18

19

20

21

22

23

24

25

26

27

28

29

30

31

S
1
8
15
22
29

M
2
9
16
23
30

F
6
13
20
27

S
7
14
21
28

December
F

15

20

TH
1

November

14

October

27

August

17

18

19

20

21

22

23

24

25

26

27

28

29

30

T
3
10
17
24
31

W TH
4
5
11 12
18 19
25 26

Calendar

January
S

March

February

TH

TH

F
1

S
2

April

TH

TH

10

11

12

10

11

12

13

13

14

15

16

17

18

19

10

11

12

13

14

15

16

10

11

12

13

14

15

16

14

15

16

17

18

19

20

25

26

22

23

24

25

26

27

F
2

S
3

20

21

22

23

24

27

28

29

30

31

17

18

19

20

21

24

25

26

27

28

17

18

19

20

21

22

23

21

22

23

24

25

26

27

28

29

30

28

29

30

TH

31

June

May
S

TH

10

11

12

13

14

15

16

17

18
25

19

20

21

22

23

24

26

27

28

29

30

31

TH

2
9
16
23
30

3
10
17
24

September

T
4
11
18
25

W TH
5
12
19
26

6
13
20
27

July

7
14
21
28

S
1
8
15
22
29

21

22

28

29

TH

10

11

12

13

10

15

16

17

18

19

20

11

12

13

14

15

16

17

23

24

25

26

27

30

31

TH

10

11

12

13

14

10

11

12

16

17

18

19

20

21

13

14

15

16

17

18

19

10

11

12

13

14

15

16

22

23

24

25

26

27

28

25

26

29

30

21

22

23

24

28

29

30

31

18

19

20

21

22

23

24

25

26

27

28

29

30

31

S
1
8
15
22
29

M
2
9
16
23
30

F
6
13
20
27

S
7
14
21
28

December
F

15

20

TH
1

November

14

October

27

August

17

18

19

20

21

22

23

24

25

26

27

28

29

30

T
3
10
17
24
31

W TH
4
5
11 12
18 19
25 26

Vaccine Name

Dose Number
2

9/12/13

9/12/13

9/12/13

HepB
BCG
OPV or OPV1

Date Given

Penta or Penta1
PCV or PCV1
OPV or OPV2
RV or RV1
Penta or Penta2
PCV or PCV2
OPV or OPV3
RV or RV2
Penta or Penta3
PCV or PCV3
OPV or OPV4
RV or RV3
MR or MR1
MR or MR2

OFF SET VACCINES:

Notes:

MILESTONES:

Vaccine Name

Dose Number

Date Given

9/12/13

9/12/13

9/12/13

10/24/13

PCV or PCV1

10/24/13

OPV or OPV2

10/24/13

10/24/13

HepB
BCG
OPV or OPV1
Penta or Penta1

RV or RV1

Penta or Penta2
PCV or PCV2
OPV or OPV3
RV or RV2
Penta or Penta3
PCV or PCV3
OPV or OPV4
RV or RV3
MR or MR1
MR or MR2

OFF SET VACCINES:

Notes:

MILESTONES:

Vaccine Name

Dose Number

Date Given

9/12/13

9/12/13

9/12/13

10/24/13

PCV or PCV1

10/24/13

OPV or OPV2

10/24/13

10/24/13

Penta or Penta2

PCV or PCV2

OPV or OPV3

11/21/13

RV or RV2

11/21/13

HepB
BCG
OPV or OPV1
Penta or Penta1

RV or RV1

11/21/13
11/21/13

Penta or Penta3
PCV or PCV3
OPV or OPV4
RV or RV3
MR or MR1
MR or MR2

OFF SET VACCINES:

Notes:

MILESTONES:

Vaccine Name

Dose Number

Date Given

9/12/13

9/12/13

9/12/13

10/24/13

PCV or PCV1

10/24/13

OPV or OPV2

10/24/13

10/24/13

Penta or Penta2

11/21/13

PCV or PCV2

11/21/13

11/21/13

11/21/13

12/19/13
12/19/13

HepB
BCG
OPV or OPV1
Penta or Penta1

RV or RV1

OPV or OPV3
RV or RV2
Penta or Penta3

PCV or PCV3

OPV or OPV4

12/19/13

12/19/13

RV or RV3

MR or MR1
MR or MR2

OFF SET VACCINES:

Notes:

MILESTONES:

Vaccine Name

Dose Number

Date Given

HepB

9/12/13

BCG

9/12/13

9/12/13

10/24/13

PCV or PCV1

10/24/13

OPV or OPV2

10/24/13

10/24/13

Penta or Penta2

11/21/13

PCV or PCV2

11/21/13

OPV or OPV3

11/21/13

RV or RV2

11/21/13

Penta or Penta3

12/19/13

PCV or PCV3

12/19/13

OPV or OPV4

12/19/13

12/19/13

6/19/14

OPV or OPV1
Penta or Penta1

RV or RV1

RV or RV3
MR or MR1

MR or MR2

OFF SET VACCINES:

Notes:

MILESTONES:

Vaccine Name

Dose Number

Date Given

9/12/13

9/12/13

9/12/13

10/24/13

PCV or PCV1

10/24/13

OPV or OPV2

10/24/13

10/24/13

Penta or Penta2

11/21/13

PCV or PCV2

11/21/13

OPV or OPV3

11/21/13

RV or RV2

11/21/13

Penta or Penta3

12/19/13

PCV or PCV3

12/19/13

OPV or OPV4

12/19/13

12/19/13

6/19/14

9/12/13

HepB
BCG
OPV or OPV1
Penta or Penta1

RV or RV1

RV or RV3
MR or MR1
MR or MR2

OFF SET VACCINES:

Notes:

MILESTONES:

Medical Contacts
Name
Number/E-mail
Dr. Paulson

(715) 495- ****

Mayo Clinic

(715) 495- ****


9-1-1

Emergency

FAQS

SAFETY

(715) 495- ****

Poison Control Center

Vaccines are very safe. The United States


long-standing vaccine safety system ensures that
vaccines are as safe as possible. Most common
side effects are typically very mild, such as pain
or swelling at the injection site.

Most side effects are very minor, like soreness


where the shot was given, fussiness, or a
Side Effects low-grade fever.These side effects typically last a
couple of days and are treatable. Serious reactions
are very rare.However, if your child experiences
any that concern you,call the doctors office.

Key:

Information

Appointment

Vaccine

Combo
vaccines

Combination vaccines protect your child against


more than one disease with a single shot. Some
common combination vaccines that are currently
used are: DTaP (diphtheria-tetanus-pertussis) and
MMR (measles-mumps-rubella).

Pain Relief

Studies have shown that babies cry less when


given a shot if they're sucking on a pacifier dipped
in sugar water or a bottle containing sweetened
water. Nursing or being held by a parent
afterward can also help stop the sting.