VACCINATION SCREENING FORM 
Department of Health and Human Services, Centers for Disease Control and Prevention 

Name (First, Last)		Date of Birth: 
  

Please answer “Yes” or “No” for the following questions. 

1. Think of all the vaccine shots you have received in your life. Is there a recent record 
of those at another doctor's office, in your home, at a school, or at your job? 		Yes 	No 

2. If you answsered “Yes” above, would you be willing to sign a form so that this information can 
be given to your doctor? 	Yes 	No 

3. Are you allergic to any medicines or foods? 		Yes 	No 

4. Have you ever had a serious reaction to a shot? 	Yes 	No 


VACCINATION SCREENING FORM 
Please answer YES or NO or fill in the answer that best fits you for the following questions. 

5. What country were you born in? 

6. Are you working at a job that pays money? 		Yes 	No 

7. What is the highest grade in school that you finished? Indicate the letter of the correct choice.
A. None 	B. Less than 6th grade 		C. 6th through 9th grade 	D. 10th through 12th grade, but did not graduate 
E. High school graduate or GED 		F. Training after high school, other than college 
(such as vocational, technical, or other taining, etc.) 
G. Some college  	H. Graduated from college 	I. Post graduate 

8. What is your race? Indicate the letter of the correct choice.
A. Black 	B. White 	C. Asian 	D. American Indian/Alaska native 	E. Other 

9. What is your ethnicity? Indicate the letter of the correct choice.
A. Hispanic (e.g., Mexican, Puerto Rican, Cuban, etc.) 		B. Non-Hispanic 


DO YOU NEED ANY VACCINE SHOTS? 
Many adults have not had all the vaccine shots that they need to prevent serious sickness. Do you know 
if you have? These lists will help you learn if you need any vaccine shots today or in the future. 


FLU SHOT 
Please answer “Yes” or “No” for the following statements. 
1. I am 50 years old or older. 		Yes 	No 

2. One or more of the following conditions applies to me:  

 I have diabetes mellitus (sugar). 	Yes No
 I have lung disease, including asthma. Yes No
 I have heart or kidney disease. 	Yes No
 I have sickle-cell disease. 		Yes No
 I have cancer or HIV/AIDS. 		Yes No
 I may be pregnant during the flu season (November through March). Yes No
 I take steroids such as prednisone. 	Yes No




3. One or more of the following situations applies to me. 	
  I live with someone who has one of the conditions listed above, that is, diabetes, 
    lung disease, heart or kidney disease, sickle-cell disease, cancer or HIV/AIDS, 
    or I live with someone who may be pregnant during the flu seaseon, 
    or I take steriods.								Yes No
  I live with or care outside the home for a child less than 2 years old. 	Yes No
  I am a health care worker. 							Yes No
  I provide essential community services. 					Yes No



 
4. I will travel to one or more of the following places: 	
	to the tropics at anytime 							Yes No
	to South America, Australia or Africa during April through September 		Yes No
	with a large group (such as a cruise ship) 					Yes No
 
 If you answered “Yes” to any of the the last three statements, you may need 
 the flu vaccine shot during the flu season (November through March). 
 

5. I already had a flu vaccine shot this season. 	Yes No




Pneumonia (PNEUMOCOCCAL) SHOT 
Please answer “Yes” or “No” for the following statements. 
1. I am an American Indian or Alaska Native. 	Yes No
 
2. I am 65 years old or older. 			Yes No
 
3. One or more of the following applies to me: 
 I have diabetes mellitus (sugar). 
 I have lung disease, not just asthma.
 I have heart, kidney, or liver disease.
 I have a drinking problem (alcoholism). 
 I have sickle-cell disease. 
 I have cancer or HIV/AIDS. 
 I do not have a spleen. 
 I have spinal fluid leak. 
 I take steroids such as prednisone. 

 



4. I am 65 years old or older and had a pneumonia (pneumococcal) vaccine shot 
when I was younger than 65, and it has been 5 years or more since I had that 
vaccine shot. 									Yes No 


If you answered “Yes” to any part of the last statement or to any of the statements just read, 
you may need the pneumonia (pneumococcal) vaccine shot. 

 I already had a pneumonia (pneumococcal) vaccine shot. 	Yes No 


 
HEPATITIS A SHOT 
Please answer “Yes” or “No” for the following statements.
 
1. One or more of the following applies to me: 
 I plan to visit a foreign country (except: Canada, Japan, Australia or Western Europe). 
 I take drugs bought on the street (use needles or snort).
 I am a man who has sex with men. 
 I have had liver disease for a long time, or I have hepatitis C.
 I have a blood-clotting disease with clotting factor infusions. 
 If you answered “Yes” to any of these statements,you may need the hepatitis A vaccine shot.

 
2. I have had hepatitis A infection or 2 hepatitis A vaccine shots.  Yes No
 
HEPATITIS B SHOT 
Please circle “Yes” or “No” for the following statements.   
1. I am under 20 years old. 								Yes No 

2. One or more of the following applies to me: 
 I am a health care or public safety worker who could be exposed to blood or body fluids. Yes No
 I recently had or was treated for a sexually transmitted disease. 			Yes No
 I had more than one sex partner during the last 6 months.    				Yes No
 I am a man who has sex with men.  							Yes No
 I have sex or live with a person with hepatitis B.  					Yes No
 I have had liver disease for a long time, or I have hepatitis C.   			Yes No
 I shoot drugs with needles.   								Yes No
 I have bad kidney disease.    								Yes No
 I provide direct services for people with developmental disabilities.  		Yes No
 I will live in Asia or Africa for more than 6 months.   				Yes No
 I come from Asia or the Pacific Islands.   						Yes No
 I have a blood-clotting disease.    							Yes No


If you answered “Yes” to any of these statements, you may need the hepatitis B vaccine shot. 

3. I have had hepatitis B infection or 3 hepatitis B vaccine shots. 		Yes No




TETANUS SHOT 
Please answer “Yes” or “No” for the following statement. 
1. It has been more than 10 years since my last tetanus booster shot.     Yes No
 
If you answered “Yes” to this statement, you may need the tetanus vaccine shot. 


MEASLES-MUMPS-RUBELLA  (MMR) SHOT 
Please answer “Yes” or “No” for the following statements: 
1. I was born in 1957 or later. 			Yes No 

2. I am a woman who was born outside of the U.S. who could become pregnant.    Yes No 

3. One or more of the following applies to me: 
 I am a health care worker. 				Yes No
 I am entering college or a trade school. 		Yes No
 I have HIV/AIDS. 					Yes No
 I plan to visit foreign countries in the future. 	Yes No

If you answered “Yes” to any of these statements,you may need the Measles-Mumps-Rubella (MMR) vaccine shot. 

4. I have had at least one Measles-Mumps-Rubella (MMR) vaccine shot. Yes No
 


To determine which vaccine shots you need, discuss your answers to these questions with your doctor or other healthcare 
provider.