Type of Date given Healthcare professional Date next

Vaccine

To order additional record cards, visit www.immunize.org/shop

Immunization Action Coalition • Saint Paul, Minn. • www.immunize.org
Number:
Patient

Last name
vaccine mo/day/yr or clinic name dose due

ADULT I M MUN IZATION RECORD

Birthdate:

healthcare professional or clinic keep it up to date.

Hepatitis B

Always carry this record with you and have your

Engerix-B, Recom-
bivax HB, Heplisav-B;
Twinrix (HepA-HepB)

Hepatitis A

(mo.)
HepA, HepA-HepB

If combo

Measles, Mumps,

–
Rubella MMR

(day)

First name
Varicella
(chickenpox) Var

Zoster (shingles)

–
Shingrix (RZV)
Zostavax (ZVL)

(yr.)
Tetanus,
Diphtheria,

Item #R2005 (10/18)

Pertussis
(whooping cough)
Tdap,Td

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

(i.e., HepA–HepB), fill in a row for each separate antigen in the combination.
generic abbreviation (e.g., PPSV23) or the trade name. For combination vaccines
Healthcare provider: List the mo/day/yr for each vaccination given. Record the

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

LAST NAME
Pneumococcal
Pneumovax 23
(PPSV23)
Prevnar 13 (PCV13)

Influenza
IIV, RIV LAIV

FIRST NAME
Human
Papillomavirus
HPV

Mening-ACWY
MenACWY

Mening-B MenB
Bexsero (MenB-4C)
Trumenba (MenB-
FHbp)

M.I.
Other

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