Adult Immunizations

• Some adults were never vaccinated as children
  
• Newer vaccines were not available when some adults were children
• Immunity can begin to fade over time As we age, we become more susceptible to serious disease caused by common infections (e.g., flu, pneumococcus)

It can sometimes be difficult to understand or keep track of exactly which vaccines you need. Use the following form to help you understand what vaccines might be important for you. Questions on the form help you and your doctor decide which vaccines you need and when to get them. You can print the form, fill it out, and take it with you to the office the next time you see your doctor. The clinician's version of the form can be distributed and used in clinics and healthcare professionals' offices.

ADULT VACCINATION SCREENING FORM

Name (First, Last)
Date of Birth:

Medical Record Number (FOR CLINIC USE ONLY)


Please answer “Yes” or “No” for the following questions.

1. Think of all the vaccine shots you have received in your life. Is there a recent record of those at another doctor's office, in your home, at a school, or at your job?
Yes No

2. If you answsered “Yes” above, would you be willing to sign a form so that this information can be given to your doctor?
Yes No

3. Are you allergic to any medicines or foods?
Yes No

4. Have you ever had a serious reaction to a shot?
Yes No

5. What country were you born in?

6. Are you working at a job that pays money?
Yes No

7. What is the highest grade in school that you finished? Indicate the letter of the correct choice.
A. None
B. Less than 6th grade
C. 6th through 9th grade
D. 10th through 12th grade, but did not graduate
E. High school graduate or GED
F. Training after high school, other than college
(such as vocational, technical, or other taining, etc.)
G. Some college
H. Graduated from college
I. Post graduate

8. What is your race? Indicate the letter of the correct choice.
A. Black
B. White
C. Asian
D. American Indian/Alaska native
E. Other

9. What is your ethnicity? Indicate the letter of the correct choice.
A. Hispanic (e.g., Mexican, Puerto Rican, Cuban, etc.)
B. Non-Hispanic

DO YOU NEED ANY VACCINE SHOTS?

Many adults have not had all the vaccine shots that they need to prevent serious sickness. Do you know if you have? These lists will help you learn if you need any vaccine shots today or in the future.

FLU SHOT

Please answer “Yes” or “No” for the following statements.
1. I am 50 years old or older.
Yes No

2. One or more of the following conditions applies to me:

• I have diabetes mellitus (sugar). Yes No
• I have lung disease, including asthma. Yes No
  
• I have heart or kidney disease. Yes No
  
• I have sickle-cell disease. Yes No
  
• I have cancer or HIV/AIDS. Yes No
  
• I may be pregnant during the flu season (November through March). Yes No
• I take steroids such as prednisone. Yes No
  

3. One or more of the following situations applies to me.

• I live with someone who has one of the conditions listed above, that is, diabetes, lung disease, heart or kidney disease, sickle-cell disease, cancer or HIV/AIDS, or I live with someone who may be pregnant during the flu seaseon, or I take steriods. Yes No
  
• I live with or care outside the home for a child less than 2 years old. Yes No
  
• I am a health care worker. Yes No
  
• I provide essential community services. Yes No
  

4. I will travel to one or more of the following places:

• to the tropics at anytime Yes No
• to South America, Australia or Africa during April through September Yes No
  
• with a large group (such as a cruise ship) Yes No
  

If you answered “Yes” to any of the the last three statements, you may need the flu vaccine shot during the flu season (November through March).

5. I already had a flu vaccine shot this season. Yes No

(FOR CLINIC USE ONLY)
Influenza Vaccine recommended Yes No
Influenza Vaccine ordered Yes No
Comments Reviewer's initials

Pneumonia (PNEUMOCOCCAL) SHOT

Please answer “Yes” or “No” for the following statements.

1. I am an American Indian or Alaska Native. Yes No

2. I am 65 years old or older. Yes No

3. One or more of the following applies to me:

• I have diabetes mellitus (sugar).
• I have lung disease, not just asthma.
  
• I have heart, kidney, or liver disease.
  
• I have a drinking problem (alcoholism).
  
• I have sickle-cell disease.
  
• I have cancer or HIV/AIDS.
  
• I do not have a spleen.
  
• I have spinal fluid leak.
  
• I take steroids such as prednisone.
  

4. I am 65 years old or older and had a pneumonia (pneumococcal) vaccine shot when I was younger than 65, and it has been 5 years or more since I had that vaccine shot. Yes No

If you answered “Yes” to any part of the last statement or to any of the statements just read, you may need the pneumonia (pneumococcal) vaccine shot.

I already had a pneumonia (pneumococcal) vaccine shot. Yes No

(FOR CLINIC USE ONLY)
Pneumonia Vaccine recommended Yes No
Pneumonia Vaccine ordered Yes No
Comments Reviewer’s initials

HEPATITIS A SHOT

Please answer “Yes” or “No” for the following statements.

1. One or more of the following applies to me:

• I plan to visit a foreign country (except: Canada, Japan, Australia or Western Europe).
  
• I take drugs bought on the street (use needles or snort).
  
• I am a man who has sex with men.
  
• I have had liver disease for a long time, or I have hepatitis C.
  
• I have a blood-clotting disease with clotting factor infusions.
  

If you answered “Yes” to any of these statements,you may need the hepatitis A vaccine shot.

2. I have had hepatitis A infection or 2 hepatitis A vaccine shots. Yes No

HEPATITIS B SHOT

Please circle “Yes” or “No” for the following statements.

1. I am under 20 years old. Yes No

2. One or more of the following applies to me:

• I am a health care or public safety worker who could be exposed to blood or body fluids. Yes No
  
• I recently had or was treated for a sexually transmitted disease. Yes No
  
• I had more than one sex partner during the last 6 months. Yes No
  
• I am a man who has sex with men. Yes No
  
• I have sex or live with a person with hepatitis B. Yes No
  
• I have had liver disease for a long time, or I have hepatitis C. Yes No
  
• I shoot drugs with needles. Yes No
  
• I have bad kidney disease. Yes No
  
• I provide direct services for people with developmental disabilities. Yes No
  
• I will live in Asia or Africa for more than 6 months. Yes No
  
• I come from Asia or the Pacific Islands. Yes No
  
• I have a blood-clotting disease. Yes No
  
  

If you answered “Yes” to any of these statements, you may need the hepatitis B vaccine shot.

3. I have had hepatitis B infection or 3 hepatitis B vaccine shots. Yes No

(FOR CLINIC USE ONLY)
Hepatitis A Vaccine recommended Yes No
Hepatitis A Vaccine ordered Yes No
Hepatitis B Vaccine recommended Yes No
Hepatitis B Vaccine ordered Yes No
Comments Reviewer’s initials

TETANUS SHOT

Please answer “Yes” or “No” for the following statement.

1. It has been more than 10 years since my last tetanus booster shot. Yes No

If you answered “Yes” to this statement, you may need the tetanus vaccine shot.

MEASLES-MUMPS-RUBELLA (MMR) SHOT

Please answer “Yes” or “No” for the following statements:

1. I was born in 1957 or later. Yes No

2. I am a woman who was born outside of the U.S. who could become pregnant. Yes No

3. One or more of the following applies to me:

• I am a health care worker. Yes No
  
• I am entering college or a trade school. Yes No
  
• I have HIV/AIDS. Yes No
  
• I plan to visit foreign countries in the future. Yes No
  

If you answered “Yes” to any of these statements,you may need the Measles-Mumps-Rubella (MMR) vaccine shot.

4. I have had at least one Measles-Mumps-Rubella (MMR) vaccine shot. Yes No

(FOR CLINIC USE ONLY)
Tetanus Vaccine recommended Yes No
Tetanus Vaccine Vaccine ordered Yes No

MMR Vaccine recommended Yes No
MMR Vaccine ordered Yes No
Comments Reviewer’s initials


Adapted from the Department of Health and Human Services Centers for Disease Control and Prevention

Are your children's immunizations up to date? Use our Vaccine Schedule program to print a customized immunization schedule for your child.

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