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| Yes/No | Date | Yes/No | Date | ||
| Cholera | Pneumonia | ||||
| Diptheria | Polio | ||||
| Hepatitis A | Rubella | ||||
| Hepatitis B | Small pox | ||||
| Influenza | Tetanus | ||||
| Measles | Tuberculosis | ||||
| Meningococcus | Typhoid | ||||
| Mumps | Varicella | ||||
| Other | Other | ||||
| SPOUSE/PARTNER | |||||
| Cholera | Pneumonia | ||||
| Diptheria | Polio | ||||
| Hepatitis A | Rubella | ||||
| Hepatitis B | Small pox | ||||
| Influenza | Tetanus | ||||
| Measles | Tuberculosis | ||||
| Meningococcus | Typhoid | ||||
| Mumps | Varicella | ||||
| Other | Other | ||||
| CHILD #1 | |||||
| Cholera | Pneumonia | ||||
| Diptheria | Polio | ||||
| Hepatitis A | Rubella | ||||
| Hepatitis B | Small pox | ||||
| Influenza | Tetanus | ||||
| Measles | Tuberculosis | ||||
| Meningococcus | Typhoid | ||||
| Mumps | Varicella | ||||
| Other | Other | ||||
| CHILD #2 | |||||
| Cholera | Pneumonia | ||||
| Diptheria | Polio | ||||
| Hepatitis A | Rubella | ||||
| Hepatitis B | Small pox | ||||
| Influenza | Tetanus | ||||
| Measles | Tuberculosis | ||||
| Meningococcus | Typhoid | ||||
| Mumps | Varicella | ||||
| Other | Other |