Healthcare Provider Office Information Form - U.s. Department Of Health And Human Services - 2015
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1
2Healthcare Provider Office Information
We believe that getting vaccinated is a critical step in protecting your health. Vaccines can help
prevent common diseases that can be serious and costly for you or your loved ones.
Each year, thousands of adults in America suffer serious health problems (and some even die)
from diseases they could be vaccinated against like whooping cough, hepatitis A and B, flu and
pneumococcal diseases, and shingles. Older adults and those with chronic health conditions are
at increased risk for complication from certain diseases.
Together, let’s take an active role in helping you and your loved ones stay healthy. To learn more
about vaccines for adults, visit
or take a quick vaccine quiz at
Please take a moment to fill out the questionnaire below to help us determine which
vaccines may be recommended for you based on your specific health status, age, and
lifestyle. Keep in mind that this list may not include every vaccine you need.
Check all that apply to you
Let’s discuss these recommended vaccines
□
•
I am 19 years or older
Seasonal Flu (Influenza) vaccine every year
•
Tetanus (Td) vaccine every 10 years
•
One time dose of whooping cough (Tdap) vaccine for all
adults who have never received Tdap vaccine
PREGNANT WOMEN SHOULD GET A TDAP VACCINE DURING EACH PREGNANCY
□
•
I am 60 years or older
Shingles (Zoster) vaccine*
□
•
I am 65 years or older
Both types of pneumococcal vaccines (one dose of conjugate
first, then one dose of polysaccharide 6-12 months later)
□
•
I didn’t receive the Human papillomavirus
HPV vaccine series (3 dose series)
(HPV) vaccine series as a child
Female age 26 or younger
o
Male age 21 or younger
o
Male age 22-26 who has sex with men, who has a weakened
o
immune system, or who has HIV
□
•
I was born in the US in 1957 or after and
Measles, mumps, rubella (MMR) vaccine* (one dose)
don’t have immunity against measles,
mumps, and rubella
□
•
I was born in the US in 1980 or after and
Varicella “chickenpox” vaccine*
don’t have immunity against chickenpox
□
•
I am a healthcare worker
Hepatitis B vaccine series
•
Measles, mumps, rubella (MMR) vaccine*
•
Varicella “chickenpox” vaccine*
□
•
I have heart disease, asthma or chronic lung
Pneumococcal polysaccharide vaccine
disease
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