For HEALTHCARE PROFESSIONAL (HCP)
Here are vaccine recommendations for this patient, based on his or her immunization self-assessment on the Centers for Disease Control and Prevention website at https://www.cdc.gov/vaccines/adultquiz. Use this chart to track when you discussed, recommended, and/or provided the suggested vaccines to your patient.
Your vaccination recommendations
Take these pages to your healthcare professional.
Visit Date:
Patient Name:
Provider Name:
Vaccine | Indications | Patient discusion and recommendation | Provided to patient |
---|---|---|---|
Seasonal Flu (Influenza) | People 6 months of age or older should get the flu vaccine. | ☐ Discussed ☐ Recommended Date: ( / / ) | ☐ Administered ☐ Referred out ☐ Declined ☐ Deferred Date: ( / / ) |
Covid-19 | People age 6 months or older should get 1 or more doses of updated (2023-2024 formula) COVID-19 vaccine. | ☐ Discussed ☐ Recommended Date: ( / / ) | ☐ Administered ☐ Referred out ☐ Declined ☐ Deferred Date: ( / / ) |
Item | Available | HCP Notes |
---|---|---|
Vaccination record | ☐ Yes ☐ No |
|
Allergies | ☐ Yes ☐ No |
|
To access the recommended adult immunization schedule and a table listing main contraindications, go to https://www.cdc.gov/vaccines/schedules/hcp/adult.html
Vaccine Information Statements (VISs) for each of the vaccines are available at https://www.cdc.gov/vaccines/hcp/vis/index.html.
Information on travel vaccine requirements and recommendations (hepatitis A and B, meningococcal, and other vaccines) are available at https://wwwnc.cdc.gov/travel/destinations/list/.
The latest versions of individual vaccine recommendations can be found at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html.