Vaccinations

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).

Information on this website is for educational and reference purposes only and should not be interpreted as specific medical advice.

Copyright © 2006

Women Physicians

Ob-Gyn Medical Group