ADULT IMMUNIZATION RECORD

Always carry this record with you and have your

healthcare professional or clinic keep it up to date.
Last name First name M.I.
Birthdate: – –
(mo.) (day) (yr.)
Patient
Number:
Immunization Action Coalition  Saint Paul, MN  www.immunize.org
To order additional record cards, visit www.immunize.org/shop
Date next
dose due
Healthcare professional
or clinic
Date given
mo/day/yr

Type of
vaccine

Mumps,
(HepA, HepA-HepB)
(HepB, HepA-HepB)

(shingles)
(VAR)
Rubella (MMR)

Diphtheria,
Vaccine

Hepatitis A
B

(Pertussis)


(chickenpox)

(Td, Tdap)
Hepatitis

Tetanus,
If combo

Varicella
Measles,

Zoster

Last name First name M.I.

Type of Date given Healthcare professional Date next
Vaccine vaccine mo/day/yr or clinic dose due

vaccines, fill in a row for each separate antigen in the combination.

Healthcare provider: List the mo/day/yr for each vaccination given. For combination

Medical notes (e.g., allergies, vaccine reactions):

Pneumococcal
(PPSV23, PCV13)

Influenza

(TIV, LAIV)






Human

Papillomavirus

(HPV4 [Gardasil],
HPV2 [Cervarix])

Meningococcal

(MCV4 [Menactra, Menveo];
MPSV4
[Menomune])

Item #R2005 (8/10)

Other



To learn more about vaccines, visit www.immunize.org