Women Physicians
GYN Medical Group
Care of Women by Women
Home
Appointments
Gynecologic Care
Teen Program
Newsletters
Provider Profiles
In the News
Vaccinations
Emergencies
Insurance
BOTOX® Therapy
Excessive Sweating
Spider Vein Treatment
Speaker Program
Related Links
Allied Professionals
Directions
Contact Us
Blog
 
  
Many adults are behind on their vaccinations. These checklists will help you determine if you need any vaccinations. Please check the boxes that apply to you.

Women Physicians is able to meet your vaccination needs with the listed vaccines.  Call our office for an appointment.

 

Influenza vaccination
I am age 50 years or older.
I am younger than age 50 years, and one or more of the following conditions or situations applies to me:
___  lung disease ___  I live in a nursing home or chronic care facility.
___  heart disease ___  I will be pregnant during the influenza season (December–March).
___  kidney disease ___  I provide essential community services.
___  diabetes ___  I am a healthcare worker.
___  HIV/AIDS ___  I am a household contact or caregiver of a person who has one of the illnesses listed at the left, is age 65 or older, or is age 0–59 months.
___  a disease that affects the immune system
___  a condition that may cause me to choke when I swallow (e.g., neuromuscular disorder, spinal cord injury, seizure disorder)     

       
I am not in one of the groups listed above, but I'd like to be vaccinated to avoid getting influenza this season.
Pneumococcal vaccination
I am age 65 years or older, and I have never had a dose of pneumococcal vaccine.
I am age 65 years or older and had one dose of pneumococcal vaccine when I was younger than 65; it has been at least 5 years since that dose.
I have one of the following health problems and I ( have ) ( have not) had a previous dose of pneumococcal vaccine:
___  lung disease (not asthma) ___  liver disease ___  organ or bone marrow transplant
___  heart disease ___  HIV/AIDS ___  generalized malignancy
___  diabetes ___  Hodgkin’s disease ___  cerebrospinal fluid leak
___  alcoholism ___  leukemia ___  sickle cell disease
___  cochlear implant ___  multiple myeloma ___  had my spleen removed
___  kidney disease ___  lymphoma ___  on medication or receiving x-ray treatment that affects my immune system
       
Tetanus-, diphtheria-, and pertussis-containing vaccination (e.g., DTP, DTaP, Tdap, or Td)
I am younger than age 65 years and have not had a pertussis-containing vaccine as an adult.
I have or will have close contact with a child younger than 12 months and have not had a pertussis-containing vaccine as an adult.
I have not yet had at least 3 tetanus- and diphtheria-containing shots.
I have had at least 3 tetanus- and diphtheria-containing shots in my lifetime, but I believe it’s been 10 years or more since I received my last shot.
I have no idea if I ever received any tetanus- and diphtheria-containing shots in school, the military, or elsewhere.
Hepatitis A vaccination
I am in one of the following risk groups, and I haven’t had the 2-dose vaccination series against hepatitis A:
 
  • I travel in countries other than the U.S., Western Europe, Canada, Japan, Australia, and New Zealand.1
  • I am a man who has sex with men.
  • I use street drugs.
  • I have chronic liver disease.
  • I have a clotting factor disorder.
I wish to receive hepatitis A vaccine to be protected against hepatitis A even though I am not in one of the above groups.
Hepatitis B vaccination
I am in one of the following risk groups, and I haven’t completed the 3-dose vaccination series against hepatitis B:
 
  • I live with a person who has long-term hepatitis B virus infection.
  • I have a bleeding disorder that requires transfusion.
  • I am or will be on kidney dialysis.
  • I am an immigrant, or my parents are immigrants from an area of the world where hepatitis B is common.2,3
  • I inject street drugs.
  • I am a sex partner of a person with hepatitis B.
  • I’ve been diagnosed with a sexually transmitted disease.
  • I have had more than one sex partner in a 6-mo. period.
  • I am a man who has sex with men.
  • I am a healthcare or public safety worker who is exposed to blood or body fluids.
  • I provide direct services for people with developmental disabilities.
  • I travel outside the U.S.1,2
I wish to receive hepatitis B vaccine to be protected against hepatitis B even though I am not in one of the above groups.
Measles-Mumps-Rubella (MMR) vaccination
I was born after 1956 and never received a dose of MMR.
I am a woman thinking about a future pregnancy and do not know if I'm immune to rubella.
I am included in one of the following groups for whom 2 doses of MMR are recommended, but I have received only 1 dose of MMR.
___  I am a healthcare worker. ___  I am entering college or a post–high school educational institution.
___  I travel internationally. ___  I had a blood test that shows I do not have immunity to rubella.
Chickenpox (Varicella) vaccination
I have never had chickenpox disease or varicella vaccination.
I'm not sure if I've had chickenpox or not.
I may become pregnant and do not know if I'm immune to chickenpox.
Meningococcal vaccination
I am (or will be) a college freshman living in a dorm.
I am traveling to an area of the world where meningococcal disease is common.1
I have sickle cell disease, or my spleen isn't working or has been removed.
Human papillomavirus vaccination
I am a woman younger than age 27 years and haven’t completed a 3-dose vaccination series against human papillomavirus.
Shingles (zoster) vaccination
I am an adult age 60 years or older and haven’t been vaccinated against shingles.
Note: Adults may need additional vaccines, such as Hib, polio, or others. Talk to your healthcare provider.
1. Call your local travel clinic to find out if additional vaccines are recommended.
2. Areas with high rates of hepatitis B include Africa, China, Korea, Southeast Asia including Indonesia and the Philippines, the Middle East except Israel, South and Western Pacific Islands, interior Amazon Basin, and certain parts of the Caribbean (i.e., Haiti and the Dominican Republic). Areas with moderate rates include South Central and Southwest Asia, Israel, Japan, Eastern and Southern Europe, Russia, and most of Central and South America.
3. Adults from these areas should be tested for hepatitis B when they receive the first dose of hepatitis B vaccine (during the same visit).