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 Use this chart to track when you discussed, recommended, and/or provided the suggested vaccines to your patient.

Centers for Disease Control and Prevention

Your vaccination recommendations

Take these pages to your healthcare professional.

Visit Date:

Patient Name:

Provider Name:

Recommended vaccinations:
(Vaccine is not needed if the patient has already been immunized, is immune, or is not due the vaccine at this time. For more information about each vaccine and its indications, see below)
VaccineIndicationsPatient discusion and recommendationProvided
to patient
Seasonal Flu (Influenza)

People 6 months of age or older should get flu vaccine.

☐ Discussed
☐ Recommended
Date: (   /   /   )
☐ Administered
☐ Referred out
☐ Declined
☐ Deferred
Date: (   /   /   )
Patient Information
Your patient has been asked to provide the following information:
Item Available HCP Notes
Vaccination record ☐ Yes
☐ No
Allergies ☐ Yes
☐ No

List questions you may have for your doctor or healthcare professional:

For more information:

To access the recommended adult immunization schedule and a table listing main contraindications, go to

Vaccine Information Statements (VISs) for each of the vaccines are available at

Information on travel vaccine requirements and recommendations (hepatitis A and B, meningococcal, and other vaccines) are available at

The latest versions of individual vaccine recommendations can be found at

Centers for Disease Control and Prevention