Add Vaccination
Vaccine Name
Name of the vaccine (e.g., MMR, DTP, Polio).
Vaccination Description
Vaccine Type
Live attenuated
Inactivated
Subunit
mRNA
Toxoid
Conjugate
Recombinant
Virus vector
The type of vaccine, such as live attenuated, inactivated, etc.
Vaccination Age Group
Newborn (0-2 months)
Infant (2-4 months)
Infant (4-6 months)
Toddler (6-12 months)
Toddler (12-18 months)
Pre-school (18 months - 3 years)
Pre-school (3-5 years)
School-age (5-7 years)
School-age (7-12 years)
Teenager (12-15 years)
Teenager (15-18 years)
The recommended age group for the vaccine.
Dosage
The amount of the vaccine to be administered.
Route of Administration
Intramuscular (IM)
Subcutaneous (SC)
Oral
Intradermal
Intranasal
Intravenous
The method by which the vaccine is administered.
Location of Administration
label
Upper arm (deltoid)
Thigh (vastus lateralis)
Buttocks
Abdomen
Shoulder
The body part where the vaccine is administered.
Manufacture
label
Abbott
ACAN
Acetlion
ALK
AstraZeneca
Baxter
Bavarian Nordic
Beijing Institute
Bharat Biotech
Biocad
Biomanguinhos
Biotech Innovations
Cadila Healthcare
Ceva
China National
Chiron
CS Laboratories
Daiichi Sankyo
Danish Institute
Dynavax
Emergent BioSolutions
EU Vaccine Group
Finlay Institute
GlaxoSmithKline
Green Cross
Gritstone Oncology
ICP Biotech
Indivior
Inovio
J Cruz Hospital
Janssen
Johnson & Johnson
Koreavac
Kymab
Lilly
Lonza
Medicago
Merck
Moderna
Mylan
Novavax
Pfizer
Sanjofi Pasteur
Serum Institute
Shinogi
Sinovac
Takeda
Valneva
Vaxart
Vectura
Wyeth
The company that produces the vaccine.
Batch/Lot Number
The unique batch or lot number of the vaccine for tracking.
Vaccination Side Effects
Pain at injection site
Redness at injection site
Swelling at injection site
Fever
Fatigue
Headache
Muscle pain
Joint pain
Chills
Nausea
Vomiting
Diarrhea
Abdominal pain
Sore throat
Cough
Runny nose
Congestion
Rash
Itching
Hives
Dizziness
Fainting
Shortness of breath
Wheezing
Swelling of face
Facial paralysis
Swollen lymph nodes
Difficulty swallowing
Irritability
Loss of appetite
Sleepiness
Insomnia
Restlessness
Muscle weakness
Difficulty moving
Blurred vision
Eye pain
Ear pain
Irritated eyes
Rapid heartbeat
Palpitations
Low blood pressure
High blood pressure
Confusion
Altered mental state
Anxiety
Depression
Skin discoloration
Excessive sweating
Skin peeling
Loss of sensation
Numbness in limbs
Tingling in limbs
Burning sensation
Tightness in chest
Swollen tongue
Difficulty speaking
Loss of coordination
Seizures
Convulsions
Shock
Body aches
Generalized weakness
Stiff neck
Back pain
Neck pain
Stomach cramps
Constipation
Indigestion
Bloating
Gas
Dry mouth
Chest pain
Hair loss
Excessive thirst
Frequent urination
Difficulty urinating
Bloody stools
Jaundice
Dry skin
Blisters
Scarring
Enlarged glands
Hiccups
Ear ringing
Flushing
Loss of taste
Loss of smell
Lightheadedness
Sensitivity to light
Hearing loss
Hoarseness
Persistent cough
Persistent vomiting
Dehydration
Shivering
Delirium
Bleeding
Blood clots
Stroke
Heart attack
Possible side effects of the vaccine.
Known Allergies
Possible Allergy Ingredients
Egg protein
Gelatin
Latex
Yeast
Aluminum
Thimerosal
Neomycin
Streptomycin
Polymyxin B
Kanamycin
Sorbitol
Phenoxyethanol
Formaldehyde
Bovine serum albumin
Casein
Soy protein
Milk protein
Peanut oil
Polysorbate 80
Benzalkonium chloride
Beta-lactoglobulin
Sodium borate
Sodium bicarbonate
Polydimethylsiloxane
Polyethylene glycol
Propylene glycol
Ascorbic acid
Glucose
Sucrose
Sodium chloride
Lactose
Magnesium stearate
Ethyl paraben
Methyl paraben
Phenol
Dextran
Zinc oxide
Citric acid
Sodium phosphate
Potassium phosphate
Calcium phosphate
Dextrose
Ethanol
Fumaric acid
Glutamate
Hydroxypropylcellulose
Hydroxypropylmethylcellulose
Hydroxylamine
Inositol
Mannitol
Microcrystalline cellulose
Sodium carbonate
Starch
Stearyl alcohol
Triglycerides
Tween 20
Tween 80
Xanthan gum
Acetone
Ammonium hydroxide
Barium sulfate
Butyl rubber
Carbon black
Cellulose acetate
Chondroitin sulfate
Copper sulfate
Dicalcium phosphate
Ethylenediaminetetraacetic acid
Ferrous sulfate
Glycerol
Glyceryl monostearate
Guar gum
Hydrochloric acid
Iodine
Isopropanol
Kaolin
Lithium
Maltodextrin
Manganese sulfate
Myristyl alcohol
Nicotinamide
Pectin
Phosphoric acid
Potassium sorbate
Procaine
Sodium sorbate
Sucrose octanoate
Sulfamic acid
Titanium dioxide
Tribasic calcium phosphate
Triclosan
Uric acid
Vinyl acetate
Zinc chloride
Zinc sulfate
Benzoic acid
Sodium nitrate
Potassium nitrate
Sodium benzoate
Isobutylparaben
Butylparaben
Details
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Information on any known allergies related to the vaccine ingredients.
Vaccinations Notes
Any additional comments or instructions for the patient or their representative.
Parent/Representative Name
Mother
Father
Guardian
Both
Grandmother
Grandfather
Other
Who is responsible for the child during vaccination.
Patient’s Health Condition
Healthy
Mild fever
Cold symptoms
Flu symptoms
Chronic illness (stable)
Chronic illness (active)
History of allergic reaction
Currently on medication
Recent infection
Recovering from infection
Undernourished
High-risk group
Immunocompromised
Recent vaccination
OK for vaccination
Not OK for vaccination
General health condition of the patient at the time of vaccination
Insurance Information
Insurance details of the patient, if applicable.
Vaccination Patients Weight
Vaccination Patients Height
Vaccination Patients Age in months
Vaccination Dose Number
First Dose
Second Dose
Third Dose
Fourth Dose
Booster Dose 1
Booster Dose 2
Booster Dose 3
Vaccination Dose Interval
1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
2 months
3 months
4 months
6 months
12 months
2 years
5 years
10 years
Vaccination Next Due Date
1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
2 months
3 months
4 months
6 months
12 months
2 years
5 years
10 years
Possible Allergic reactions
label
Anaphylaxis
Rash
Hives
Swelling
Shortness of breath
Wheezing
Dizziness
Low blood pressure
Nausea
Vomiting
Diarrhea
Fever
Itching
Redness
Muscle weakness
Joint pain
Headache
Tachycardia
Facial swelling
Seizures
Chills
Abdominal pain
Sore throat
Difficulty swallowing
Blurred vision
Tightness in chest
Swollen tongue
Lightheadedness
Fatigue
Skin peeling
Blue lips
Weakness
Loss of consciousness
Confusion
Rapid heartbeat
Slurred speech
Fainting
Widespread skin redness
Blisters
Difficulty breathing
Difficulty speaking
Irregular heartbeat
Extreme thirst
Loss of coordination
Anxiety
Irritability
Pain at injection site
Swelling at injection site
Redness at injection site
Stomach cramps
Facial numbness
Excessive sweating
Swollen hands
Swollen feet
Chest pain
Sneezing
Difficulty urinating
Loss of bowel control
Hoarseness
Skin rash with fluid
Joint swelling
Muscle pain
Loss of sensation
Cyanosis
Burning sensation
Numbness in limbs
Difficulty moving
Blood in stool
High fever
Shock
Paralysis
Altered mental state
Excessive salivation
Persistent cough
Flushing
Irritated eyes
Ear pain
Loss of appetite
Severe itching
Back pain
Neck stiffness
Generalized weakness
Palpitations
Swollen glands
Runny nose
Persistent vomiting
Jaundice
Painful swelling
Dehydration
Body aches
Shivering
Delirium
Hair loss
Skin discoloration
Tongue swelling
Bleeding
Convulsions
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