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.

Immunization Type Date(s)
Influenza(Usually given to people over 65 years of age or to people with chronic asthma or chronic obstructive pulmonary disease.)



Tetanus and Diptheria (Td)(Usually given every 10 years.)  
Pneumococcal(Usually given to prevent pneumonia in certain patients at risk.) __Yes __No __Need revaccination?If so, reason:
Meningococcal(Usually given to prevent meningitis in certain patients at high risk.) __Yes __NoReason:
Hepatitis B __Yes __NoReason:

Request a Refill

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