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上海小白卡英文翻譯模板

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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

 

 

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

 

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

 

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

 

MMR

2003.3.20

2005.3.11

2010.9.16

MMR44A42B

F0396

2009120101

 

Varicella Vaccine

2002.5.20

2014.11.12

200202001

201202009-1

 

 

 

 

 

Influenza Vaccine

2010.1.5

 

 

 

 

 

 

 

 

Contraindication

 

 

 

 

Allergy History

 

 

 

 

 

No

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Record of Abnormal Reaction

No

 

 

 

 

 

 

 

 

 

 

 

 

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