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Adult Immunization Record
Keeping track of your immunizations as an adult is an important self-care step that can prevent a lot of confusion in the future. Click on the printer icon at the top of the page to make a copy. Fill out with pen and keep with your other health records.
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Immunization Type |
Date(s) |
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Influenza
(Usually given to people over 65 years of age or to people with chronic asthma or chronic obstructive pulmonary disease.)
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Tetanus and Diptheria (Td)
(Usually given every 10 years.) |
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Pneumococcal
(Usually given to prevent pneumonia in certain patients at risk.) |
__Yes __No __Need revaccination?
If so, reason: |
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Meningococcal
(Usually given to prevent meningitis in certain patients at high risk.) |
__Yes __No
Reason: |
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Hepatitis B |
__Yes __No
Reason: |
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Others |
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