Adult Immunization Record Card - Free Download
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(mo.) (day) (yr.)
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ADULT IMMUNIZATION RECORD
Always carry this record with you and have your
health professional or clinic keep it up to date.
Last name First name M.I.
Birthdate:
Patient
Number:
–
–
Dose Type of Date given Health professional Date next
(units) vaccine mo/day/yr or clinic dose due
Hep B 1
2
3
Hep A 1
2
*
MMR
1
2
Varicella 1
(chickenpox)
2
Td
(Tetanus,
diphtheria)
Combination vaccines should always be documented under each antigen.
If combo*
A second dose may be
needed in some people
