Adult Vaccination - Patient Self-Screening Form

The "Patient Self-Screening Form" is a checklist for adult patients to use while waiting for a visit with a healthcare provider to determine what vaccines may be recommended for them based on:
• age
• lifestyle
• health conditions
• job
• other factors

Healthcare providers can then review and discuss the completed form with you to recommend and administer any needed vaccines.

This form is available for download in:
• English
• Spanish
• Russian
• Traditional Chinese
• Simplified Chinese