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Healthcare Provider Office Information Form - U.s. Department Of Health And Human Services - 2015 Page 2

Healthcare Provider Office Information

Check all that apply to you

Let’s discuss these recommended vaccines

□

•

I have type 1 or type 2 diabetes

Hepatitis B vaccine series

•

Pneumococcal polysaccharide vaccine

□

•

I have a weakened immune system

Both types of pneumococcal vaccines (one dose of conjugate

first, then one dose of polysaccharide ≥8 weeks later)

•

HPV vaccine series (if 26 years of age or younger and not

previously vaccinated)

•

Hib vaccine (post-hematopoietic stem cell transplant only)

□

•

I have HIV

Hepatitis B vaccine series

•

Both types of pneumococcal vaccines (one dose of conjugate

first, then one dose of polysaccharide >8 weeks later)

•

HPV vaccine series (if 26 years of age or younger and not

previously vaccinated)

□

•

I have chronic liver disease

Hepatitis A vaccine series

•

Hepatitis B vaccine series

•

Pneumococcal polysaccharide vaccine

□

•

I do not have a spleen or my spleen does

Hib vaccine

not work well

•

Meningococcal vaccine

•

Both types of pneumococcal vaccines (one dose of conjugate

first, then one dose of polysaccharide ≥8 weeks later)

□

•

I am a man who has sex with men

Hepatitis A vaccine series

•

Hepatitis B vaccine series

•

HPV vaccine series (if 26 years of age or younger and not

previously vaccinated)

□

•

I am a laboratory worker and may be

Hepatitis A vaccine series

routinely exposed to isolates of Neisseria

•

Hepatitis B vaccine series

meningitidis, or specimens potentially

•

Meningococcal vaccine

containing hepatitis A or hepatitis B virus

□

•

I am a college freshman living in a residence

Meningococcal vaccine

•

hall

Measles, mumps, rubella (MMR) vaccine*

□

•

I am planning to travel out of the U.S.

Talk to your healthcare professional to learn which vaccines

you may need based on locations of travel.

*This is a live vaccine and should not be given to people who have a very weakened immune system, including

those with a CD4 count less than 200, or to pregnant women.

February 2015

Healthcare Provider Office Information Form - U.s. Department Of Health And Human Services - 2015 Page 2

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