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I was going to go back through and check spelling...but this headache that has decided to creep up on me thinks it's a bad idea.



Child’s Name: _________________________

Parent’s/Guardian’s Name(s):__________________________________________ ___

My child’s health care provider, ______________________________ has advised me that my child (named above)
should receive the following vaccines:
Recommended Declined
[ ] [ ] Hepatitis B vaccine .
[ ] [ ] Diphtheria, Tetanus, a cellular Pertussis (DTaP) vaccine .
[ ] [ ] Diphtheria Tetanus (DT or dT) vaccine .
[ ] [ ] Haemophilus influenzae type b (Hib) vaccine .
[ ] [ ] Pneumococcal conjugate (PC) vaccine .
[ ] [ ] Polio vaccine (IPV) .
[ ] [ ] Measles, mumps, rubella (MMR) vaccine .
[ ] [ ] Varicella (chickenpox) vaccine .
[ ] [ ] Influenza (flu) vaccine .
[ ] [ ] Meningococcal vaccine .
[ ] [ ] Hepatitis A vaccine .
[ ] [ ] Other __________________________________________

I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s) explaining the vaccine(s) and the disease(s) they prevent. I have had the opportunity to discuss these with my child’s health care provider, who has answered all of my questions regarding the recommended vaccine(s). I understand the following:

The intended purpose of recommending the above listed vaccine(s)
The risks and benefits of the recommended vaccine(s)

If my child does not receive the vaccine(s), the consequences may include:

-Contracting the illness the vaccine should prevent.
Including but not limited to: Aching joints, Blood infections, Brain damage, Cough, Death, Dehydration, Ear infections, Fever, Flu, Jaundice, Liver damage or failure, Meningitis, Muscle weakness, Paralysis, Paralysis, Pneumonia, Rash, Runny nose, Severe throat infection, Swelling of the glands behind the ears, Swelling of the saliva glands, Temporary liver inflammation, Vomiting or Diarrhea.

-Possibly transmitting the disease to others
-The need for my child to stay out of daycare or school during disease outbreaks.

If my child does receive the vaccine(s), the consequences may include:

-Contracting the illness the vaccine are supposed to prevent.
Including but not limited to*: Arthritis, Birth defects., Bleeding disorders, Blue color from poor circulation, Brain Dysfunction, Bruising throughout body, Chronic arthritis, Deafness, Death, Diabetes, Encephalopathy, Eye inflammation, Facial and arm paralysis, Fatigue, Fever, Flu-like symptoms, Fussiness, Gullain-Barre Syndrome, Hair loss, Headache, Heart inflammation, Heart Palpitations, Inflamed pancreas, Inflammation of the blood vessels, Intussusception, Joint and muscle soreness, Loss of appetite, Low platelet levels, Lupus, Measles infection, Migraines, Mild intestinal infection, Minor liver damage, Multiple sclerosis, Mumps infection, Mumps meningitis, Nerve Dysfunctions, Nerve inflammation, Numbness, Pain and swelling of the lymph nodes, Redness, Rubella infection, Seizures, Seizures (not associated with fever), Serious HIB infection, Sever allergic reactions, Shock, Skin infections, Stevens-Johnson syndrome, Stroke, Swelling, Visual problems, Weakness.

-Possibly transmitting the disease to others.
-Suffering from any of the adverse events listed in the package insert(s) and possibly adverse events not yet listed and/or associated with the vaccine.

My health care provider, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention have all strongly recommended that the vaccine(s) be given based on the information they have been given by the drug companies producing the vaccines.

I am not giving consent for the vaccine(s) recommended for my child, as indicated above, by checking the appropriate box under the column titled “Declined.”

I know I may re-address this issue with my health care provider at any time.

I acknowledge that I have read this document in its entirety and fully understand it.






* POLIO: I have been informed of the risk of my child developing paralytic disease and meningitis associated with poliomyelitis. I understand that even under epidemic conditions, natural polio produces no symptoms in over 90% of those exposed to it.(1) I understand that there have been no cases of wild polio in the US in the last 20 years and that those cases which have been documented have been caused by the vaccine.(2)
I understand the following side effects for the vaccine are possible:
Killed virus polio: temperature of *102° in up to 38%, sleepiness, fussiness, crying, decreased appetite, vomiting, Guillain-Barré Syndrome and allergic reaction in those allergic to neomycin, polymyxin B and streptomycin. Precautions include those who have had a previous negative reaction, pregnant women, and possibly those with HIV/AIDS or otherwise compromised immune systems.
Live virus polio: Reactions include contraction of polio by those who have received the virus and by those who have come into contact with body fluids and wastes of the immunized person. Paralytic symptoms may follow contraction of polio. Live virus is reportedly shed for up to 8 weeks after the inoculation. Guillain-Barré Syndrome has also been noted. Not recommended for use in households where someone has a compromised immune system, for pregnant women, or where a previous reaction has been reported.(3)
Killed virus Ipol® is grown on monkey kidney cells, contains formaldehyde, and triple antibiotics. Poliovax® is grown on cells from an aborted baby, contains formaldehyde, cow serum and triple antibiotic solution.(4) The monkey kidney cells used in the original killed polio vaccine contains SIV-40 and has been found in tumor cells of children whose parent's were vaccinated against polio using the contaminated virus.(5) The live vaccine is grown on monkey kidney cells, antibiotics and calf serum.

HEMOPHILUS INFLUENZAE B: I have been informed of the risk of my child developing meningitis (although this vaccine will not protect the child from meningitis from all other forms such as pneumococcus, and meningococcus, viruses, and fungi), pneumonia, and infections of the blood, joints, bone, and soft tissue associated with Hemophilus Influenzae B. I understand that this disease is most likely in children up to 15 months of age and is fatal in 3-6% of children who contract it. Incidence of this disease today is low and the vaccine has not proven to be highly effective in 41% of cases, according to some studies.(6) Treatment is available.
The vaccine is often combined with the DPT which has the highest reaction rate of any vaccine available today. Reactions include: contracting HIB, localized pain, erythema and induration, fever >100.6°, irritability, lethargy, anorexia, rhinorrhea, diarrhea, vomiting, cough, when administered alone. Reactions occurred in up to 30% of patients. When administered in conjunction with the DPT, reactions include local tenderness erythema and induration, fever >100.8°, irritability, drowsiness, anorexia, diarrhea, vomiting, persistent crying, seizures, urticaria, hives, renal failure, Guillain-Barré Syndrome and death. Reactions occurred in up to 77.9% of patients.(7)
The vaccine contains yeast, thimerosal (mercury derivative), and diphtheria toxoid when given alone.(8)

PERTUSSIS: I have been informed of the risk of my child developing whooping cough, pneumonia, convulsions, inflammation of the brain, and death associated with pertussis. I understand the disease is rarely fatal, with a 99.8% recovery rate. It is most serious and life-threatening in children under 6 months old, but there are adequate methods of treatment available.(9)
The vaccine is most often given in conjunction with diphtheria and tetanus as the DPT or as the DaPT.
Pertussis vaccine may cause: fevers >106, pain swelling, diarrhea, projectile vomiting, excessive sleepiness, high--pitched screaming, inconsolable crying bouts, seizures, convulsions, collapse, shock, breathing problems, brain damage and SIDS. One in 600 suffer a severe reaction in one study (10) and 1 in 875 suffered shock-collapse and convulsions.(11) Those in the 2nd study were only tracked for the first 48 hours following immunization. A more recent study indicates that 1 in 100 react with convulsions, collapse, or high-pitched screaming and 1 in 3 of those cases sustained permanent brain damage.(12) In a study of 103 children who died of SIDS, 70% died within 3 weeks of the DPT vaccine and 37% of those died within the first week.(13)
The DaPT is recommended as a safer option for vaccination. Side effects of the DaPT were only tracked for 72 hours and included: tenderness, erythema, induration, fever >102.2°, drowsiness, fretfulness, vomiting, upper respiratory infection, diarrhea, rash, febrile seizures, persistent or unusual crying, lethargy, hypronic-hyporesponsive episode, urticaria, anaphylactic shock, convulsions, encephalopathy, mono- and polyneuropathies and death.(14) Not recommended for children under 15 months or for those who have not had 3 injections of the DPT.
Either form of the vaccine contains thimerosal (mercury derivative), formaldehyde, and aluminum phosphate.(15)

DIPHTHERIA: I have been informed of the risk of my child developing paralysis, heart failure, or respiratory failure associated with diphtheria. I have also been informed that there have only been 5 cases reported annually since 1980.(16) I am also aware that diphtheria is rarely fatal and treated with antibiotics and bed rest. (17)
The Diphtheria component is most often given within the DPT or DaPT and includes the same side effects and reactions as those listed for pertussis.

TETANUS: I have been informed of the risk of my child developing fatal neuromuscular disease related to tetanus. I understand that the incidence of tetanus is low, and there is an antitoxin, should we decline the immunization. I understand that contracting tetanus does not provide life-long immunity, and neither does the vaccine. I understand that to prevent more severe reactions from the vaccine, the tetanus component has been so significantly "diluted" that it is clinically ineffective.(18) I understand that the death rate for properly treated cases of tetanus may be as high as 20%.(19)
Side effects of the tetanus vaccine alone include: high fever, pain, recurrent abscess formation, inner ear nerve damage, demyelinating neuropathy, anaphylactic shock and loss of consciousness.(20)
Tetanus given in the DPT or DaPT shot include the same side effects and reactions as those listed for pertussis.

RUBELLA (MEASLES): I have been informed of the risk of my child developing pneumonia, encephalitis (inflammation of the brain), degenerative disease of the nervous system with convulsions (subacute sclerosing panencephalitis) related to rubella. I understand the death rate for measles is .03 in 100,000.(21) I understand that since 1984, over 55% of documented, confirmed cases of measles have been in fully immunized persons.(22)
I understand that the greatest risk of the measles vaccine may be to push the incidence of this disease into the late teens and adulthood where it is more likely to be fatal or cause more adverse and long-term effects.(23)
The measles vaccine is a live vaccine, and carries the risk that it will cause the patient to contract measles. Other adverse reactions include: stinging or burning at the injection site, anaphylaxis, fever up to one month following injection, rash, cough, rhinitis, erythema multiforme, lymphadenopathy, urticaria, diarrhea, febrile convulsions, seizures, thrombocytopenia, purpura, vasculitis, optic neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and encephalopathy, ocular palsies, Guillain-Barré Syndrome, ataxia, and subacute sclerosing panencephalitis.(24)
Measles vaccine is most often given as a part of the MMR which includes the following side effects: burning or stinging at injection site, malaise, sore throat, cough, rhinitis, headache, dizziness, fever, rash, nausea, vomiting, diarrhea, erythema, induration, tenderness, lymphadenopathy, parotitius, orchitis, nerve deafness, thrombocytopenia, purpura, allergic reactions, urticaria, polyneuritis, arthralgia, arthritis, anaphylaxis, vasculitis, otitis media, conjunctivitis, febrile convulsions, seizures, syncope, erythema multiforme, optic neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and encephalopathy, ocular palsies, Guillain-Barré Syndrome, ataxia, subacute sclerosing panencephalitis,(25) and a recent study from Europe indicates that there may be a link between the MMR (measles/mumps/rubella) vaccine and autism and irritable bowel syndrome.(26)
Measles vaccine contains chick embryo cells, neomycin, sorbitol and hydrolyzed gelatin. MMR contains all live vaccines, chick embryo, cells from aborted babies, neomycin, sorbitol and hydrolyzed gelatin.(27)

MUMPS: I have been informed of the risk of my child developing inflammation of the testicles, joints, kidneys, and/or thyroid, and hearing impairment related to mumps. I understand that mumps is rarely harmful in childhood, and that most of the above risks occur when mumps is contracted in adolescence or adulthood.(28)
I understand that there is a Mumps vaccine which poses the following risks: contraction of mumps from the live vaccine, burning or stinging at the injection site, anaphylaxis, cough, rhinitis, fever, diarrhea, vasculitis, parotitis, orchitis, purpura, urticaria, erythema multiforme, optic neuritis, retrobulbar neuritis, syncope, encephalitis, febrile seizures, and nerve deafness.(29)
Mumps is usually given in the MMR and may cause those side effects and adverse reactions as noted in the measles section above.
Mumps vaccine is live and should not be given to pregnant women. It is cultured in chick embryos and contains sorbitol and hydrolyzed gelatin.(30)

RUBELLA (GERMAN MEASLES): I have been informed of the risk of my child developing inflammation of the brain or joints, and of the risk of birth defects (including eye defects, heart defects, deafness, mental retardation, growth failure, jaundice, and disorders of blood clotting) in infants born to mothers who contract rubella during pregnancy, related to rubella. Therefore, I understand that the greatest risk to my child may be if she never contracts rubella as a child, but when she is pregnant and it damages her unborn child. If she contract rubella in childhood, she is immune for life, and prior to the vaccine 85% of the population was immune.(31) I understand that if she is not immune as an adult, she can choose to take the vaccine prior to becoming pregnant. I understand that many of those who contract rubella have been immunized (up to 80%). (32)
Adverse reactions from the vaccine among teenage girls is 5-10% and 30% in adult women.(33) Adverse reactions include: contracting rubella from the live virus in the vaccine, burning or stinging at the site, lymphadenopathy, urticaria, rash, malaise, sore throat, fever, headache, dizziness, nausea, vomiting, diarrhea, polyneuritis, arthralgia, arthritis, local pain and inflammation, erythema multiforme, cough, rhinitis, vasculitis, anaphylaxis, syncope, optic neuritis, retrobulbar neuritis, papillitis, Guillain-Barré Syndrome, encephalitis, thrombocytopenia, purpura, and Chronic Fatigue Syndrome. (34)
Rubella is most often administered in the MMR and may cause those side effects and adverse reactions listed under measles.
Rubella is cultured on the tissue of an aborted child. This child was the 27th child aborted and tested by researchers due to exposure to rubella in a pregnant woman. It contains neomycin, sorbitol and hydrolyzed gelatin.(35)

HEPATITIS B: I have been informed of the risk of my child developing Hepatitis B viral infection which can cause chronic inflammation of the liver leading to cirrhosis, liver cancer, and possibly death. I understand that my child's risk of developing Hepatitis B is low if I am not a carrier or infected, if my child does not engage in promiscuous sex or use drugs. I understand that there is antibiotic treatment for HepB and that most of those who contract it recover.(36) I understand that the HepB vaccine only contains strains of HepB and is not effective against HepA, C, D, E, F, or G.
I understand that the HepB vaccine has the following side effect and adverse reactions: induration, erythema, swelling, fever, headache, dizziness, pain, prutitus, ecchymosis, sweating, malaise, chills, weakness, flushing, tingling, hypotension, flu-like symptoms, upper respiratory illness, nausea, anorexia, abdominal pain and cramping, vomiting, constipation, diarrhea, lymphadenopathy, pain or stiffness in muscles and joints, arthralgia, myalgia, back pain, rash, urticaria, petechiae, sleepiness, insomnia, irritability, agitation, anaphylaxis, angioedema, arthritis, tachycardia/palpitations, bronchospasm, abnormal liver function tests, dyspepsia, migraine, syncope, paresis neuropathy, hypothesis, paresthesis, Guillain-Barré Syndrome, Bell's Palsy, transverse myelitis, optic neuritis, multiple sclerosis, thrombocytopenia, eczema, purpura, herpes zoster, erythema modosum, alopecia, conjunctivitis, keratisis, visual disturbances, vertigo, tinnitus, earache, and dysuria.(37) The studies only followed patients for 4 days post-vaccination.
The most commonly used HepB vaccine contains thimerosal, although a relatively new release does not contain thimerosal. The vaccine also contains: aluminum hydroxide, yeast protein, and phosphate buffers.(38)

VARICELLA (CHICKENPOX): I have been informed of the risk of my child developing chicken pox which could potentially result in pneumonia, secondary skin or generalized infections, or, if caught during pregnancy, birth defects in the baby. I understand chicken pox is generally benign in children, but results in significant lost hours at work for parents. Chicken pox in adults often manifests as shingles, a chronic and painful condition. I also understand that contracting chicken pox later in life may increase my risk for herpes simplex.
Side effects and adverse reactions for the chicken pox vaccine include: contracting chicken pox from the live vaccine (27%), pain and redness at site, swelling, erythema, rash, pruritus, hematoma, induration, stiffness, upper respiratory illness, cough, irritability/nervousness, fatigue, disturbed sleep, diarrhea, loss of appetite, vomiting, otitis, diaper rash/contact rash, nausea, eye complaints, chills, lymphadenopathy, myalgia, lower respiratory illness, headache, malaise, abdominal pain, other rash, allergic reactions including rash and hives, stiff neck, heat rash/prickly heat, arthralgia, eczema/dry skin/dermatitis, constipation, itching, pneunonitis, febrile seizures, and cold/canker sore.(39)
Varicella vaccine is cultured on cells from aborted babies, and guinea pig cell cultures. It contains live virus, monosodium glutamate (msg), sucrose, phosphate, processed gelatin, neomycin and fetal calf serum. (40)

HEPATITIS A (HAV): I have been informed of the risk of my child developing HAV which could potentially result in prolonged or relapsed hepatitis, but will not result in chronic hepatitis disease. (41) HAV usually causes mild "flu-like" illness, jaundice, severe stomach pains and diarrhea; and, in rare cases may result in death. Infection confers lifelong immunity. (42) I understand that the CDC admits that good personal hygiene (handwashing) and proper santitation can prevent HAV. (43)
HAV infection is spread by contaminated water or food, infected food handlers, unsanitary conditions following natural disasters, ingestion of raw or undercooked shellfish, institutionalized individuals, children not yet toilet trained, blood transfusions or sharing needles with infected people. Transmission is most likely in developing countries where sanitation is poor and infection rate of children under 5 is 90%. Fatality rate is less than .6% overall, and 70% of those in patients over 49 years, many of whom have underlying liver disease. (44) Other at-risk populations include those living on American Indian reservations and in Alaskan Native villages, homosexually active men, IV drug users, people using clotting factor concentrates and international travelers. (45)
Side effects and adverse reactions from the vaccine include: injection-site soreness, headache, fever, malaise, induration, redness, swelling, fatigue, anorexia, nausea, pruritis, rash, utricaria, pharyngitis, upper respiratory tract infections, abdominal pain, diarrhea, dysgeusia, vomiting, arthralgia, elevated cratine phosphokinase, myalgia, lymphadenopathy, hypertonic episodes, insomnia, photophobia, and vertigo. (46)
Aborted fetal tissue is an ingredient in the Havrix® Hep A vaccine, as is formaldehyde, aluminum hydroxide and 2-phenozyethanol.(47)
There is currently a combination Hep A and B vaccine, Twinrix®, being tested in the UK. (48) Twinrix is grown in human cell cultures, contains 2-phenoxyethanol, neomycin sulfate, polysorbate, tromentamol and formaldehyde. (49)

PNEUMOCOCCAL: I have been informed of the risk of my child developing pneumococcal disease which could result in meningitis, blood infection, pneumonia and/or ear infections. Iunderstand studies indicate that this vaccine may only decrease ear infections by 9%, and only result in a 20% reduction in chronic ear infections and ear tube insertion in that group.
I understand that my child has a 7.5:5,000 chance of deveoping this disease if he or she is under age 2 and a 1:5000 chance of developing it if over age 2. Risk factors for developing this disease are: immunoglobulin deficiency, nephrotic syndrome, Hodgkin's disease, congenital or acquired immunodeficiency, some upper respiratory infections, splenic dysfunctions, splenectomy or organ transplant. This vaccine (PCV) was originally marketed for immunocompromised children. (50) This vaccine is contraindicated to children with thrombocytopenia, coagualtion disorders, or sensitivity to diphtheria toxoid.(51)
Possible side effects and complications from the vaccine include: erythema, induration, tenderness, interference of limb movement, inflamation, fever, irritability, drowsiness, restless sleep, decreased appetite, vomiting, diarrhea, fussiness, rash, hives, bronchitis, asthma, pneumonia, otitis media (ear infection), sepsis, seizure, anaphylaxis and death.(52) Recipients were followed for 3 days and almost 10% of the subjects made a visit to the emergency room in the follow-up period. There were 8 cases of SIDS in the 17,066 subjects involved in the trial.(53) Note: Children in the studies' control group received another experimental vaccine, so there have been no trial studies done with children who received no vaccine.(54)
Prevnar contains .125 mg of aluminum sulfate, protein polysaccharides from 7 strains of strep. pneumoniae bacteria, diphtheria toxin, casamino acids, yeast extract. Studies indicate that it may interfere with the safety and efficacy of other vaccines.(55)

FLU: I have been informed of the risk of my child developing influenza, which could result in hospitalization for respiratory complications, pneumonia and death. I understand less than 175 people died from the flu in the US during 2003. I understand that there is no guarantee that the flu strains chosen for this year will be the flu strains that are active this year. I understand that from 1999 - 2003, 70 - 80% of the sniffles, fevers, and body aches did not test positive for influenza regardless of the flu strain used.
The most common reactions to injected flu vaccines, which begin within 12 hours of vaccination and can last several days are: fever, fatigue, painful joints and headache. The most serious reaction that has been associated with flu vaccine is Guillain-Barré Syndrome (GBS), which occurs most often within two to four weeks of vaccination. GBS is an immune mediated nerve disorder characterized by muscle weakness, unsteady gait, numbness, tingling, pain and sometimes paralysis of one or more limbs or the face. Recovery takes several months and can include residual disability. Less than 5 percent of GBS cases end in death. Brain and nerve disorders such as encephalopathy, optic neuritis, partial facial paralysis, and brachial plexus neuropathy as well as vasculitis also have been reported following the flu vaccine, although a definite causal relationship has not been established. (56) A tenfold increase in Alzheimer's disease exists for those who receive the flu vaccine five years in a row. (57)
FluMist: Reported adverse effects in children include runny nose, nasal congestion, cough, sore throat, headache, irritability, decreased activity, fever, chills, muscle aches, and vomiting. In adults the most common side effects were runny nose, cough, sore throat, headache, muscle aches, fever, chills and tiredness or weakness. Other adverse events that occurred in children were abdominal pain, asthma, bronchitis, conjunctivitis, viral syndrome, otitis media (middle ear infection), and wheezing or shortness of breath.(58)
Fluzone is propagated in chick embryos. It contains formaldehyde, sucrose, polyethylene glycol, sodium phosphate, salt and thimerosal.(59) Fluvirin is prepared in chicken eggs and contains thimerosal, neomycin, polymyxin, and phosphate-buffered saline. (60)
FluMist is a live vaccine propagated in chicken eggs, and contains potassium phosphate, sucrose (table sugar) and monosodium glutamate (MSG). (61)

HUMAN PAPILLOMAVIRUS (HPV): I have been informed of the risk of developing HPV. HPV is a sexually-transmitted disease that can cause genital warts, and it’s most severe stage, cervical cancer. I understand that there are more than 100 forms of HPV and that the currently available vaccine only covers four of the strains; current screening for HPV looks for 13 “high risk” strains. The CDC estimated that 20 million people in the US had HPV and many strains cause no harm. (62) I understand current research shows that most women will quickly clear the infection on their own, and very few will develop pre-cancerous or cancerous lesions. Use of the vaccine will not cure HPV infection, and the duration of the longest HPV vaccine studies covered less than 50% of the time it takes to progress from CIN 2 or 3 levels to cervical cancer, so 100% efficacy cannot realistically be proven. (63) HPV vaccination does not take the place of routine Pap screens. (64)
The most common reactions to the HPV vaccines were pain, swelling, redness and itching at the injection site. More than 90% of vaccine test subjects and more than 85% of subjects receiving the aluminum-containing placebo experienced at least one of these reactions. (65) Other reactions from the vaccine included: systemic fever, nausea, nasopharyngitis, dizziness, diarrhea, vomiting, myalgia, cough, upper respiratory tract infection, malaise, arthralgia, insomnia and nasal congestion. More severe reactions included headache, gastroenteritis, appendicitis, pelvic inflammatory disease, asthma, pulmonary embolism, sepsis, arrhythmia, juvenile arthritis, rheumatoid arthritis, lupus, arthritis and reactive arthritis. There were also statistically higher levels of birth defects in women who got pregnant within 30 days of receiving the vaccine and in more than 30 cases of birth defects in women who became pregnant after 30 days from either Gardasil® or the aluminum-containing placebo. (66)
Gardasil® is currently the only HPV vaccine approved for use and contains 225mcg of aluminum hydroxyphosphate sulfate, sodium chloride, L-histidine, polysorbate 80, sodium borate, water, and proteins from HPV strains 6, 11, 16 and 18 grown in yeast fermentation medium. (67)

Reference List
1. M. Burnet and D. White, The Natural History of Infectious Disease (Cambridge, 1972), p. 16.
2. Strebel, et al, "Epidemology in the U.S. One Decade After the Last Reported Case of Indigenous Wild Virus Associated Disease," Clinical Infectious Diseases, (Center for Disease Control, February 1992), pp. 568-79.
3. Physician's Desk Reference (PDR), 50th Edition; Medical Economics, 1996, p. 1388-1390.
4. Ibid, p. 885-886 and 891-892.
5. J. Butel, et al; "Molecular Evidence of Simian Virus 40 Infections in Children", The Journal of Infectious Diseases ; September 1999;180:884-887.
6. PDR, 50th Edition, p. 872-875.
7. Ibid.
8. Ibid.
9. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering, (Spring1984),p. 34.
10. Immunization: Survey of Recent Research, (United States Department of Health and Human Services, April 1983), p. 76.
11. "Nature and Rates of Adverse Reactions Associated with DPT and DT Immunizations...," Pediatrics, Volume 68, No. 5 (November 1981).
12. Walene James, Immunization the Reality Behind the Myth, (South Hadley, Massachusetts: Bergin & Garvey, 1988), p. 14.
13. W.C. Torch, "Diptheria-pertussis-tetanus (DPT) immunization: A potential cause of sudden infant death syndrome (SIDS)," (Amer. Academy of Neurology, 34th Annual Meeting, Apr 25 - May 1, 1982), Neurology 32(4), pt. 2.
14. PDR, p. 875-879 and 892-895.
15. Ibid.
16. Robert Mendelsohn, M.D., How to Raise A Healthy Child...In Spite of your Doctor (Chicago: Contemporary Books, 1984), p.223.
17. Ibid. 244-246
18. Isaac Golden, Ph.D., Vaccination? A Review of Risks and Alternatives, (Geelong, Victoria, Australia: Arum Healing Centre, 1991), p. 31
19. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering, (Spring1984),p. 34.
20. Isaac Golden, Ph.D., Vaccination? A Review of Risks and Alternatives; p. 71
21. R. Mendoholson; How to Raise a Healthy Child; p. 217.
22. John Frank Jr., M.D., et al. "Measles Elimination - Final Impediments," 20th Immunization Conference Proceedings, May 6-9, 1985, p. 21.
23. Infectious Diseases (January 1982), p. 21.
24. PDR, p. 1610-1611.
25. DR, p. 1687-1689.
26. Sara Solovitch, "Do vaccines spur autism in kids?", San Jose Mercury News, 5/25/99.
27. PDR, p. 1687-89, 1610-1611.
28. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering, (Spring1984),p. 35.
29. PDR, 1708-1709.
30. Ibid.
31. R. Mendoholson; How to Raise a Healthy Child; p. 218.
32. Dr. Beverley Allan, Australian Nurses Journal, (May 1978).
33. Hannah Allen, Don't Get Stuck: The Case Against Vaccinations..., (Oldsmar, FL: Natural Hygiene Press, 1985), p. 144.
34. DR, p. 1697-1699.
35. Ibid and Attenuation Of RA 27/3 Rubella Virus in WI-38 Human Diploid Cells; Amer J Dis Child vol 118 Aug 1969 and Studies of Immunization With Living Rubella Virus ; Arch J Dis Child vol 110 Oct 1965.
36. John Hanchette, "Safety of controversial hepatitis B vaccine at center of debate" Gannett News Service, 5/18/99.
37. PDR, p. 1744-1747, 2482-2484.
38. Ibid.
39. PDR, p. 1762-1765.
40. Ibid.
41. CDC Viral Hepatitis A - Fact Sheet, 9/29/00; www.cdc.gov/ncidod/diseases/hepatitis/a/fact.htm
42. CDC Hepatitis A Vaccine Vaccine Information Statement; 8/25/98
43. CDC Hepatitis A Facts, 11/16/00
44. Mosby's GenRX®, 10th Ed., Hepatitis A Vaccine (003158) as posted on MDConsult website
45. CDC Hepatitis A Vaccine Vaccine Information Statement; 8/25/98 and CDC Hepatitis A Vaccine Vaccine Information Statement; 8/25/98
46. Mosby's GenRX@, Hepatitis A Vaccine
47. Ibid.
48. "Combined hepatitis A/B vaccine offers fast protection," Reuters Health, 4/12/00
49. Vaccines and Their Ingredients, 6/24/99; www.909shot.com
50. Michael Horwin, MA; "Prevnar: A Critical Review of a New Childhood Vaccine" 9/19/00.
51. Prevnar package insert, Wyeth Lederle, 2/17/00
52. Ibid.
53. Horwin; "Prevnar: A Critical Review"
54. Dr. Erdem Cantekin, Ph.D.; "Pneumocaoccal Vaccine and Otitis Media", NVIC's 2nd Intl. Public Conference, 9/8/00.
55. Horwin; "Prevnar: A Critical Review"
56. Physician's Desk Reference (PDR), 53rd Edition; Medical Economics, 1999, p. 2326, 3464
57. Dr. Russell Blaylock, MD; “The Truth Behind the Vaccine Coverup” 9/22/04; www.mercola.com/2004/sep/22/blaylock_vaccine_coverup.htm
57. Fluzone 2003-2004 Formula, Aventis Product information as of July 2003
58. Dr. Sherry Tenpenny, DO, “FluMist Vaccine: Nothing to Sneeze At!” 10/23/2003; www.nmaseminars.com .
59. Influenza Virus Vaccine Live, Intranasal FluMist 2003-2004 Formula, Package Insert (Circular) June 16, 2003.
60. “New Preservative Free Flu Vaccine Approved,” http://www.accessdata.fda.gov/psn/tr...pt.cfm?show=10
61. Dr. Sherry Tenpenny, DO, “FluMist Vaccine: Nothing to Sneeze At!”
62. CDC HPV Fact Sheet, http://www.cdc.gov/std/HPV/STDFact-HPV.htm
63. Dr. Clayton Young, MD, FACOG, “OBGYN Against ACIP HPV Vaccine Decision,” 6/27/2006
64. CDC HPV Fact Sheet, http://www.cdc.gov/std/HPV/STDFact-HPV.htm
65. Merck Professional Privider Information Sheet: Gardasil® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recominant Vaccine. www.Merck.com
66. Daron G Ferris, “Facing the Future: The Impact of HPV Vaccination on Adolescent Health,” and “An Update of Clinical Trial Results With Preventative HPV Vaccines” http://www.medscape.com/viewprogram/5334
67. Merck Professional Privider Information Sheet: Gardasil® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recominant Vaccine. www.Merck.com

*Complied by Kathryn E. Rateliff, CCD, CCM, CCCE, GSM, PE, BFE
October, 1999 and most recently revised August 10, 2006



Parent/Guardian Signature ________________________________ Date ___________________


Witness ______________________________________________ Date ___________________
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I ran it through my spell check and I only found two non-disease spelling errors/words stuck together under PNEUMOCOCCAL which I fixed in my quote.

Quote:
Originally Posted by CaraNicole View Post
I was going to go back through and check spelling...but this headache that has decided to creep up on me thinks it's a bad idea.



Child’s Name: _________________________

Parent’s/Guardian’s Name(s):__________________________________________ ___

My child’s health care provider, ______________________________ has advised me that my child (named above)
should receive the following vaccines:
Recommended Declined
[ ] [ ] Hepatitis B vaccine .
[ ] [ ] Diphtheria, Tetanus, a cellular Pertussis (DTaP) vaccine .
[ ] [ ] Diphtheria Tetanus (DT or dT) vaccine .
[ ] [ ] Haemophilus influenzae type b (Hib) vaccine .
[ ] [ ] Pneumococcal conjugate (PC) vaccine .
[ ] [ ] Polio vaccine (IPV) .
[ ] [ ] Measles, mumps, rubella (MMR) vaccine .
[ ] [ ] Varicella (chickenpox) vaccine .
[ ] [ ] Influenza (flu) vaccine .
[ ] [ ] Meningococcal vaccine .
[ ] [ ] Hepatitis A vaccine .
[ ] [ ] Other __________________________________________

I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s) explaining the vaccine(s) and the disease(s) they prevent. I have had the opportunity to discuss these with my child’s health care provider, who has answered all of my questions regarding the recommended vaccine(s). I understand the following:

The intended purpose of recommending the above listed vaccine(s)
The risks and benefits of the recommended vaccine(s)

If my child does not receive the vaccine(s), the consequences may include:

-Contracting the illness the vaccine should prevent.
Including but not limited to: Aching joints, Blood infections, Brain damage, Cough, Death, Dehydration, Ear infections, Fever, Flu, Jaundice, Liver damage or failure, Meningitis, Muscle weakness, Paralysis, Paralysis, Pneumonia, Rash, Runny nose, Severe throat infection, Swelling of the glands behind the ears, Swelling of the saliva glands, Temporary liver inflammation, Vomiting or Diarrhea.

-Possibly transmitting the disease to others
-The need for my child to stay out of daycare or school during disease outbreaks.

If my child does receive the vaccine(s), the consequences may include:

-Contracting the illness the vaccine are supposed to prevent.
Including but not limited to*: Arthritis, Birth defects., Bleeding disorders, Blue color from poor circulation, Brain Dysfunction, Bruising throughout body, Chronic arthritis, Deafness, Death, Diabetes, Encephalopathy, Eye inflammation, Facial and arm paralysis, Fatigue, Fever, Flu-like symptoms, Fussiness, Gullain-Barre Syndrome, Hair loss, Headache, Heart inflammation, Heart Palpitations, Inflamed pancreas, Inflammation of the blood vessels, Intussusception, Joint and muscle soreness, Loss of appetite, Low platelet levels, Lupus, Measles infection, Migraines, Mild intestinal infection, Minor liver damage, Multiple sclerosis, Mumps infection, Mumps meningitis, Nerve Dysfunctions, Nerve inflammation, Numbness, Pain and swelling of the lymph nodes, Redness, Rubella infection, Seizures, Seizures (not associated with fever), Serious HIB infection, Sever allergic reactions, Shock, Skin infections, Stevens-Johnson syndrome, Stroke, Swelling, Visual problems, Weakness.

-Possibly transmitting the disease to others.
-Suffering from any of the adverse events listed in the package insert(s) and possibly adverse events not yet listed and/or associated with the vaccine.

My health care provider, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention have all strongly recommended that the vaccine(s) be given based on the information they have been given by the drug companies producing the vaccines.

I am not giving consent for the vaccine(s) recommended for my child, as indicated above, by checking the appropriate box under the column titled “Declined.”

I know I may re-address this issue with my health care provider at any time.

I acknowledge that I have read this document in its entirety and fully understand it.






* POLIO: I have been informed of the risk of my child developing paralytic disease and meningitis associated with poliomyelitis. I understand that even under epidemic conditions, natural polio produces no symptoms in over 90% of those exposed to it.(1) I understand that there have been no cases of wild polio in the US in the last 20 years and that those cases which have been documented have been caused by the vaccine.(2)
I understand the following side effects for the vaccine are possible:
Killed virus polio: temperature of *102° in up to 38%, sleepiness, fussiness, crying, decreased appetite, vomiting, Guillain-Barré Syndrome and allergic reaction in those allergic to neomycin, polymyxin B and streptomycin. Precautions include those who have had a previous negative reaction, pregnant women, and possibly those with HIV/AIDS or otherwise compromised immune systems.
Live virus polio: Reactions include contraction of polio by those who have received the virus and by those who have come into contact with body fluids and wastes of the immunized person. Paralytic symptoms may follow contraction of polio. Live virus is reportedly shed for up to 8 weeks after the inoculation. Guillain-Barré Syndrome has also been noted. Not recommended for use in households where someone has a compromised immune system, for pregnant women, or where a previous reaction has been reported.(3)
Killed virus Ipol® is grown on monkey kidney cells, contains formaldehyde, and triple antibiotics. Poliovax® is grown on cells from an aborted baby, contains formaldehyde, cow serum and triple antibiotic solution.(4) The monkey kidney cells used in the original killed polio vaccine contains SIV-40 and has been found in tumor cells of children whose parent's were vaccinated against polio using the contaminated virus.(5) The live vaccine is grown on monkey kidney cells, antibiotics and calf serum.

HEMOPHILUS INFLUENZAE B: I have been informed of the risk of my child developing meningitis (although this vaccine will not protect the child from meningitis from all other forms such as pneumococcus, and meningococcus, viruses, and fungi), pneumonia, and infections of the blood, joints, bone, and soft tissue associated with Hemophilus Influenzae B. I understand that this disease is most likely in children up to 15 months of age and is fatal in 3-6% of children who contract it. Incidence of this disease today is low and the vaccine has not proven to be highly effective in 41% of cases, according to some studies.(6) Treatment is available.
The vaccine is often combined with the DPT which has the highest reaction rate of any vaccine available today. Reactions include: contracting HIB, localized pain, erythema and induration, fever >100.6°, irritability, lethargy, anorexia, rhinorrhea, diarrhea, vomiting, cough, when administered alone. Reactions occurred in up to 30% of patients. When administered in conjunction with the DPT, reactions include local tenderness erythema and induration, fever >100.8°, irritability, drowsiness, anorexia, diarrhea, vomiting, persistent crying, seizures, urticaria, hives, renal failure, Guillain-Barré Syndrome and death. Reactions occurred in up to 77.9% of patients.(7)
The vaccine contains yeast, thimerosal (mercury derivative), and diphtheria toxoid when given alone.(8)

PERTUSSIS: I have been informed of the risk of my child developing whooping cough, pneumonia, convulsions, inflammation of the brain, and death associated with pertussis. I understand the disease is rarely fatal, with a 99.8% recovery rate. It is most serious and life-threatening in children under 6 months old, but there are adequate methods of treatment available.(9)
The vaccine is most often given in conjunction with diphtheria and tetanus as the DPT or as the DaPT.
Pertussis vaccine may cause: fevers >106, pain swelling, diarrhea, projectile vomiting, excessive sleepiness, high--pitched screaming, inconsolable crying bouts, seizures, convulsions, collapse, shock, breathing problems, brain damage and SIDS. One in 600 suffer a severe reaction in one study (10) and 1 in 875 suffered shock-collapse and convulsions.(11) Those in the 2nd study were only tracked for the first 48 hours following immunization. A more recent study indicates that 1 in 100 react with convulsions, collapse, or high-pitched screaming and 1 in 3 of those cases sustained permanent brain damage.(12) In a study of 103 children who died of SIDS, 70% died within 3 weeks of the DPT vaccine and 37% of those died within the first week.(13)
The DaPT is recommended as a safer option for vaccination. Side effects of the DaPT were only tracked for 72 hours and included: tenderness, erythema, induration, fever >102.2°, drowsiness, fretfulness, vomiting, upper respiratory infection, diarrhea, rash, febrile seizures, persistent or unusual crying, lethargy, hypronic-hyporesponsive episode, urticaria, anaphylactic shock, convulsions, encephalopathy, mono- and polyneuropathies and death.(14) Not recommended for children under 15 months or for those who have not had 3 injections of the DPT.
Either form of the vaccine contains thimerosal (mercury derivative), formaldehyde, and aluminum phosphate.(15)

DIPHTHERIA: I have been informed of the risk of my child developing paralysis, heart failure, or respiratory failure associated with diphtheria. I have also been informed that there have only been 5 cases reported annually since 1980.(16) I am also aware that diphtheria is rarely fatal and treated with antibiotics and bed rest. (17)
The Diphtheria component is most often given within the DPT or DaPT and includes the same side effects and reactions as those listed for pertussis.

TETANUS: I have been informed of the risk of my child developing fatal neuromuscular disease related to tetanus. I understand that the incidence of tetanus is low, and there is an antitoxin, should we decline the immunization. I understand that contracting tetanus does not provide life-long immunity, and neither does the vaccine. I understand that to prevent more severe reactions from the vaccine, the tetanus component has been so significantly "diluted" that it is clinically ineffective.(18) I understand that the death rate for properly treated cases of tetanus may be as high as 20%.(19)
Side effects of the tetanus vaccine alone include: high fever, pain, recurrent abscess formation, inner ear nerve damage, demyelinating neuropathy, anaphylactic shock and loss of consciousness.(20)
Tetanus given in the DPT or DaPT shot include the same side effects and reactions as those listed for pertussis.

RUBELLA (MEASLES): I have been informed of the risk of my child developing pneumonia, encephalitis (inflammation of the brain), degenerative disease of the nervous system with convulsions (subacute sclerosing panencephalitis) related to rubella. I understand the death rate for measles is .03 in 100,000.(21) I understand that since 1984, over 55% of documented, confirmed cases of measles have been in fully immunized persons.(22)
I understand that the greatest risk of the measles vaccine may be to push the incidence of this disease into the late teens and adulthood where it is more likely to be fatal or cause more adverse and long-term effects.(23)
The measles vaccine is a live vaccine, and carries the risk that it will cause the patient to contract measles. Other adverse reactions include: stinging or burning at the injection site, anaphylaxis, fever up to one month following injection, rash, cough, rhinitis, erythema multiforme, lymphadenopathy, urticaria, diarrhea, febrile convulsions, seizures, thrombocytopenia, purpura, vasculitis, optic neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and encephalopathy, ocular palsies, Guillain-Barré Syndrome, ataxia, and subacute sclerosing panencephalitis.(24)
Measles vaccine is most often given as a part of the MMR which includes the following side effects: burning or stinging at injection site, malaise, sore throat, cough, rhinitis, headache, dizziness, fever, rash, nausea, vomiting, diarrhea, erythema, induration, tenderness, lymphadenopathy, parotitius, orchitis, nerve deafness, thrombocytopenia, purpura, allergic reactions, urticaria, polyneuritis, arthralgia, arthritis, anaphylaxis, vasculitis, otitis media, conjunctivitis, febrile convulsions, seizures, syncope, erythema multiforme, optic neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and encephalopathy, ocular palsies, Guillain-Barré Syndrome, ataxia, subacute sclerosing panencephalitis,(25) and a recent study from Europe indicates that there may be a link between the MMR (measles/mumps/rubella) vaccine and autism and irritable bowel syndrome.(26)
Measles vaccine contains chick embryo cells, neomycin, sorbitol and hydrolyzed gelatin. MMR contains all live vaccines, chick embryo, cells from aborted babies, neomycin, sorbitol and hydrolyzed gelatin.(27)

MUMPS: I have been informed of the risk of my child developing inflammation of the testicles, joints, kidneys, and/or thyroid, and hearing impairment related to mumps. I understand that mumps is rarely harmful in childhood, and that most of the above risks occur when mumps is contracted in adolescence or adulthood.(28)
I understand that there is a Mumps vaccine which poses the following risks: contraction of mumps from the live vaccine, burning or stinging at the injection site, anaphylaxis, cough, rhinitis, fever, diarrhea, vasculitis, parotitis, orchitis, purpura, urticaria, erythema multiforme, optic neuritis, retrobulbar neuritis, syncope, encephalitis, febrile seizures, and nerve deafness.(29)
Mumps is usually given in the MMR and may cause those side effects and adverse reactions as noted in the measles section above.
Mumps vaccine is live and should not be given to pregnant women. It is cultured in chick embryos and contains sorbitol and hydrolyzed gelatin.(30)

RUBELLA (GERMAN MEASLES): I have been informed of the risk of my child developing inflammation of the brain or joints, and of the risk of birth defects (including eye defects, heart defects, deafness, mental retardation, growth failure, jaundice, and disorders of blood clotting) in infants born to mothers who contract rubella during pregnancy, related to rubella. Therefore, I understand that the greatest risk to my child may be if she never contracts rubella as a child, but when she is pregnant and it damages her unborn child. If she contract rubella in childhood, she is immune for life, and prior to the vaccine 85% of the population was immune.(31) I understand that if she is not immune as an adult, she can choose to take the vaccine prior to becoming pregnant. I understand that many of those who contract rubella have been immunized (up to 80%). (32)
Adverse reactions from the vaccine among teenage girls is 5-10% and 30% in adult women.(33) Adverse reactions include: contracting rubella from the live virus in the vaccine, burning or stinging at the site, lymphadenopathy, urticaria, rash, malaise, sore throat, fever, headache, dizziness, nausea, vomiting, diarrhea, polyneuritis, arthralgia, arthritis, local pain and inflammation, erythema multiforme, cough, rhinitis, vasculitis, anaphylaxis, syncope, optic neuritis, retrobulbar neuritis, papillitis, Guillain-Barré Syndrome, encephalitis, thrombocytopenia, purpura, and Chronic Fatigue Syndrome. (34)
Rubella is most often administered in the MMR and may cause those side effects and adverse reactions listed under measles.
Rubella is cultured on the tissue of an aborted child. This child was the 27th child aborted and tested by researchers due to exposure to rubella in a pregnant woman. It contains neomycin, sorbitol and hydrolyzed gelatin.(35)

HEPATITIS B: I have been informed of the risk of my child developing Hepatitis B viral infection which can cause chronic inflammation of the liver leading to cirrhosis, liver cancer, and possibly death. I understand that my child's risk of developing Hepatitis B is low if I am not a carrier or infected, if my child does not engage in promiscuous sex or use drugs. I understand that there is antibiotic treatment for HepB and that most of those who contract it recover.(36) I understand that the HepB vaccine only contains strains of HepB and is not effective against HepA, C, D, E, F, or G.
I understand that the HepB vaccine has the following side effect and adverse reactions: induration, erythema, swelling, fever, headache, dizziness, pain, prutitus, ecchymosis, sweating, malaise, chills, weakness, flushing, tingling, hypotension, flu-like symptoms, upper respiratory illness, nausea, anorexia, abdominal pain and cramping, vomiting, constipation, diarrhea, lymphadenopathy, pain or stiffness in muscles and joints, arthralgia, myalgia, back pain, rash, urticaria, petechiae, sleepiness, insomnia, irritability, agitation, anaphylaxis, angioedema, arthritis, tachycardia/palpitations, bronchospasm, abnormal liver function tests, dyspepsia, migraine, syncope, paresis neuropathy, hypothesis, paresthesis, Guillain-Barré Syndrome, Bell's Palsy, transverse myelitis, optic neuritis, multiple sclerosis, thrombocytopenia, eczema, purpura, herpes zoster, erythema modosum, alopecia, conjunctivitis, keratisis, visual disturbances, vertigo, tinnitus, earache, and dysuria.(37) The studies only followed patients for 4 days post-vaccination.
The most commonly used HepB vaccine contains thimerosal, although a relatively new release does not contain thimerosal. The vaccine also contains: aluminum hydroxide, yeast protein, and phosphate buffers.(38)

VARICELLA (CHICKENPOX): I have been informed of the risk of my child developing chicken pox which could potentially result in pneumonia, secondary skin or generalized infections, or, if caught during pregnancy, birth defects in the baby. I understand chicken pox is generally benign in children, but results in significant lost hours at work for parents. Chicken pox in adults often manifests as shingles, a chronic and painful condition. I also understand that contracting chicken pox later in life may increase my risk for herpes simplex.
Side effects and adverse reactions for the chicken pox vaccine include: contracting chicken pox from the live vaccine (27%), pain and redness at site, swelling, erythema, rash, pruritus, hematoma, induration, stiffness, upper respiratory illness, cough, irritability/nervousness, fatigue, disturbed sleep, diarrhea, loss of appetite, vomiting, otitis, diaper rash/contact rash, nausea, eye complaints, chills, lymphadenopathy, myalgia, lower respiratory illness, headache, malaise, abdominal pain, other rash, allergic reactions including rash and hives, stiff neck, heat rash/prickly heat, arthralgia, eczema/dry skin/dermatitis, constipation, itching, pneunonitis, febrile seizures, and cold/canker sore.(39)
Varicella vaccine is cultured on cells from aborted babies, and guinea pig cell cultures. It contains live virus, monosodium glutamate (msg), sucrose, phosphate, processed gelatin, neomycin and fetal calf serum. (40)

HEPATITIS A (HAV): I have been informed of the risk of my child developing HAV which could potentially result in prolonged or relapsed hepatitis, but will not result in chronic hepatitis disease. (41) HAV usually causes mild "flu-like" illness, jaundice, severe stomach pains and diarrhea; and, in rare cases may result in death. Infection confers lifelong immunity. (42) I understand that the CDC admits that good personal hygiene (handwashing) and proper santitation can prevent HAV. (43)
HAV infection is spread by contaminated water or food, infected food handlers, unsanitary conditions following natural disasters, ingestion of raw or undercooked shellfish, institutionalized individuals, children not yet toilet trained, blood transfusions or sharing needles with infected people. Transmission is most likely in developing countries where sanitation is poor and infection rate of children under 5 is 90%. Fatality rate is less than .6% overall, and 70% of those in patients over 49 years, many of whom have underlying liver disease. (44) Other at-risk populations include those living on American Indian reservations and in Alaskan Native villages, homosexually active men, IV drug users, people using clotting factor concentrates and international travelers. (45)
Side effects and adverse reactions from the vaccine include: injection-site soreness, headache, fever, malaise, induration, redness, swelling, fatigue, anorexia, nausea, pruritis, rash, utricaria, pharyngitis, upper respiratory tract infections, abdominal pain, diarrhea, dysgeusia, vomiting, arthralgia, elevated cratine phosphokinase, myalgia, lymphadenopathy, hypertonic episodes, insomnia, photophobia, and vertigo. (46)
Aborted fetal tissue is an ingredient in the Havrix® Hep A vaccine, as is formaldehyde, aluminum hydroxide and 2-phenozyethanol.(47)
There is currently a combination Hep A and B vaccine, Twinrix®, being tested in the UK. (48) Twinrix is grown in human cell cultures, contains 2-phenoxyethanol, neomycin sulfate, polysorbate, tromentamol and formaldehyde. (49)

PNEUMOCOCCAL: I have been informed of the risk of my child developing pneumococcal disease which could result in meningitis, blood infection, pneumonia and/or ear infections. I understand studies indicate that this vaccine may only decrease ear infections by 9%, and only result in a 20% reduction in chronic ear infections and ear tube insertion in that group.
I understand that my child has a 7.5:5,000 chance of deveoping this disease if he or she is under age 2 and a 1:5000 chance of developing it if over age 2. Risk factors for developing this disease are: immunoglobulin deficiency, nephrotic syndrome, Hodgkin's disease, congenital or acquired immunodeficiency, some upper respiratory infections, splenic dysfunctions, splenectomy or organ transplant. This vaccine (PCV) was originally marketed for immunocompromised children. (50) This vaccine is contraindicated to children with thrombocytopenia, coagualtion disorders, or sensitivity to diphtheria toxoid.(51)
Possible side effects and complications from the vaccine include: erythema, induration, tenderness, interference of limb movement, inflammation, fever, irritability, drowsiness, restless sleep, decreased appetite, vomiting, diarrhea, fussiness, rash, hives, bronchitis, asthma, pneumonia, otitis media (ear infection), sepsis, seizure, anaphylaxis and death.(52) Recipients were followed for 3 days and almost 10% of the subjects made a visit to the emergency room in the follow-up period. There were 8 cases of SIDS in the 17,066 subjects involved in the trial.(53) Note: Children in the studies' control group received another experimental vaccine, so there have been no trial studies done with children who received no vaccine.(54)
Prevnar contains .125 mg of aluminum sulfate, protein polysaccharides from 7 strains of strep. pneumoniae bacteria, diphtheria toxin, casamino acids, yeast extract. Studies indicate that it may interfere with the safety and efficacy of other vaccines.(55)

FLU: I have been informed of the risk of my child developing influenza, which could result in hospitalization for respiratory complications, pneumonia and death. I understand less than 175 people died from the flu in the US during 2003. I understand that there is no guarantee that the flu strains chosen for this year will be the flu strains that are active this year. I understand that from 1999 - 2003, 70 - 80% of the sniffles, fevers, and body aches did not test positive for influenza regardless of the flu strain used.
The most common reactions to injected flu vaccines, which begin within 12 hours of vaccination and can last several days are: fever, fatigue, painful joints and headache. The most serious reaction that has been associated with flu vaccine is Guillain-Barré Syndrome (GBS), which occurs most often within two to four weeks of vaccination. GBS is an immune mediated nerve disorder characterized by muscle weakness, unsteady gait, numbness, tingling, pain and sometimes paralysis of one or more limbs or the face. Recovery takes several months and can include residual disability. Less than 5 percent of GBS cases end in death. Brain and nerve disorders such as encephalopathy, optic neuritis, partial facial paralysis, and brachial plexus neuropathy as well as vasculitis also have been reported following the flu vaccine, although a definite causal relationship has not been established. (56) A tenfold increase in Alzheimer's disease exists for those who receive the flu vaccine five years in a row. (57)
FluMist: Reported adverse effects in children include runny nose, nasal congestion, cough, sore throat, headache, irritability, decreased activity, fever, chills, muscle aches, and vomiting. In adults the most common side effects were runny nose, cough, sore throat, headache, muscle aches, fever, chills and tiredness or weakness. Other adverse events that occurred in children were abdominal pain, asthma, bronchitis, conjunctivitis, viral syndrome, otitis media (middle ear infection), and wheezing or shortness of breath.(58)
Fluzone is propagated in chick embryos. It contains formaldehyde, sucrose, polyethylene glycol, sodium phosphate, salt and thimerosal.(59) Fluvirin is prepared in chicken eggs and contains thimerosal, neomycin, polymyxin, and phosphate-buffered saline. (60)
FluMist is a live vaccine propagated in chicken eggs, and contains potassium phosphate, sucrose (table sugar) and monosodium glutamate (MSG). (61)

HUMAN PAPILLOMAVIRUS (HPV): I have been informed of the risk of developing HPV. HPV is a sexually-transmitted disease that can cause genital warts, and it’s most severe stage, cervical cancer. I understand that there are more than 100 forms of HPV and that the currently available vaccine only covers four of the strains; current screening for HPV looks for 13 “high risk” strains. The CDC estimated that 20 million people in the US had HPV and many strains cause no harm. (62) I understand current research shows that most women will quickly clear the infection on their own, and very few will develop pre-cancerous or cancerous lesions. Use of the vaccine will not cure HPV infection, and the duration of the longest HPV vaccine studies covered less than 50% of the time it takes to progress from CIN 2 or 3 levels to cervical cancer, so 100% efficacy cannot realistically be proven. (63) HPV vaccination does not take the place of routine Pap screens. (64)
The most common reactions to the HPV vaccines were pain, swelling, redness and itching at the injection site. More than 90% of vaccine test subjects and more than 85% of subjects receiving the aluminum-containing placebo experienced at least one of these reactions. (65) Other reactions from the vaccine included: systemic fever, nausea, nasopharyngitis, dizziness, diarrhea, vomiting, myalgia, cough, upper respiratory tract infection, malaise, arthralgia, insomnia and nasal congestion. More severe reactions included headache, gastroenteritis, appendicitis, pelvic inflammatory disease, asthma, pulmonary embolism, sepsis, arrhythmia, juvenile arthritis, rheumatoid arthritis, lupus, arthritis and reactive arthritis. There were also statistically higher levels of birth defects in women who got pregnant within 30 days of receiving the vaccine and in more than 30 cases of birth defects in women who became pregnant after 30 days from either Gardasil® or the aluminum-containing placebo. (66)
Gardasil® is currently the only HPV vaccine approved for use and contains 225mcg of aluminum hydroxyphosphate sulfate, sodium chloride, L-histidine, polysorbate 80, sodium borate, water, and proteins from HPV strains 6, 11, 16 and 18 grown in yeast fermentation medium. (67)

Reference List
1. M. Burnet and D. White, The Natural History of Infectious Disease (Cambridge, 1972), p. 16.
2. Strebel, et al, "Epidemology in the U.S. One Decade After the Last Reported Case of Indigenous Wild Virus Associated Disease," Clinical Infectious Diseases, (Center for Disease Control, February 1992), pp. 568-79.
3. Physician's Desk Reference (PDR), 50th Edition; Medical Economics, 1996, p. 1388-1390.
4. Ibid, p. 885-886 and 891-892.
5. J. Butel, et al; "Molecular Evidence of Simian Virus 40 Infections in Children", The Journal of Infectious Diseases ; September 1999;180:884-887.
6. PDR, 50th Edition, p. 872-875.
7. Ibid.
8. Ibid.
9. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering, (Spring1984),p. 34.
10. Immunization: Survey of Recent Research, (United States Department of Health and Human Services, April 1983), p. 76.
11. "Nature and Rates of Adverse Reactions Associated with DPT and DT Immunizations...," Pediatrics, Volume 68, No. 5 (November 1981).
12. Walene James, Immunization the Reality Behind the Myth, (South Hadley, Massachusetts: Bergin & Garvey, 1988), p. 14.
13. W.C. Torch, "Diptheria-pertussis-tetanus (DPT) immunization: A potential cause of sudden infant death syndrome (SIDS)," (Amer. Academy of Neurology, 34th Annual Meeting, Apr 25 - May 1, 1982), Neurology 32(4), pt. 2.
14. PDR, p. 875-879 and 892-895.
15. Ibid.
16. Robert Mendelsohn, M.D., How to Raise A Healthy Child...In Spite of your Doctor (Chicago: Contemporary Books, 1984), p.223.
17. Ibid. 244-246
18. Isaac Golden, Ph.D., Vaccination? A Review of Risks and Alternatives, (Geelong, Victoria, Australia: Arum Healing Centre, 1991), p. 31
19. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering, (Spring1984),p. 34.
20. Isaac Golden, Ph.D., Vaccination? A Review of Risks and Alternatives; p. 71
21. R. Mendoholson; How to Raise a Healthy Child; p. 217.
22. John Frank Jr., M.D., et al. "Measles Elimination - Final Impediments," 20th Immunization Conference Proceedings, May 6-9, 1985, p. 21.
23. Infectious Diseases (January 1982), p. 21.
24. PDR, p. 1610-1611.
25. DR, p. 1687-1689.
26. Sara Solovitch, "Do vaccines spur autism in kids?", San Jose Mercury News, 5/25/99.
27. PDR, p. 1687-89, 1610-1611.
28. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering, (Spring1984),p. 35.
29. PDR, 1708-1709.
30. Ibid.
31. R. Mendoholson; How to Raise a Healthy Child; p. 218.
32. Dr. Beverley Allan, Australian Nurses Journal, (May 1978).
33. Hannah Allen, Don't Get Stuck: The Case Against Vaccinations..., (Oldsmar, FL: Natural Hygiene Press, 1985), p. 144.
34. DR, p. 1697-1699.
35. Ibid and Attenuation Of RA 27/3 Rubella Virus in WI-38 Human Diploid Cells; Amer J Dis Child vol 118 Aug 1969 and Studies of Immunization With Living Rubella Virus ; Arch J Dis Child vol 110 Oct 1965.
36. John Hanchette, "Safety of controversial hepatitis B vaccine at center of debate" Gannett News Service, 5/18/99.
37. PDR, p. 1744-1747, 2482-2484.
38. Ibid.
39. PDR, p. 1762-1765.
40. Ibid.
41. CDC Viral Hepatitis A - Fact Sheet, 9/29/00; www.cdc.gov/ncidod/diseases/hepatitis/a/fact.htm
42. CDC Hepatitis A Vaccine Vaccine Information Statement; 8/25/98
43. CDC Hepatitis A Facts, 11/16/00
44. Mosby's GenRX®, 10th Ed., Hepatitis A Vaccine (003158) as posted on MDConsult website
45. CDC Hepatitis A Vaccine Vaccine Information Statement; 8/25/98 and CDC Hepatitis A Vaccine Vaccine Information Statement; 8/25/98
46. Mosby's GenRX@, Hepatitis A Vaccine
47. Ibid.
48. "Combined hepatitis A/B vaccine offers fast protection," Reuters Health, 4/12/00
49. Vaccines and Their Ingredients, 6/24/99; www.909shot.com
50. Michael Horwin, MA; "Prevnar: A Critical Review of a New Childhood Vaccine" 9/19/00.
51. Prevnar package insert, Wyeth Lederle, 2/17/00
52. Ibid.
53. Horwin; "Prevnar: A Critical Review"
54. Dr. Erdem Cantekin, Ph.D.; "Pneumocaoccal Vaccine and Otitis Media", NVIC's 2nd Intl. Public Conference, 9/8/00.
55. Horwin; "Prevnar: A Critical Review"
56. Physician's Desk Reference (PDR), 53rd Edition; Medical Economics, 1999, p. 2326, 3464
57. Dr. Russell Blaylock, MD; “The Truth Behind the Vaccine Coverup” 9/22/04; www.mercola.com/2004/sep/22/blaylock_vaccine_coverup.htm
57. Fluzone 2003-2004 Formula, Aventis Product information as of July 2003
58. Dr. Sherry Tenpenny, DO, “FluMist Vaccine: Nothing to Sneeze At!” 10/23/2003; www.nmaseminars.com .
59. Influenza Virus Vaccine Live, Intranasal FluMist 2003-2004 Formula, Package Insert (Circular) June 16, 2003.
60. “New Preservative Free Flu Vaccine Approved,” http://www.accessdata.fda.gov/psn/tr...pt.cfm?show=10
61. Dr. Sherry Tenpenny, DO, “FluMist Vaccine: Nothing to Sneeze At!”
62. CDC HPV Fact Sheet, http://www.cdc.gov/std/HPV/STDFact-HPV.htm
63. Dr. Clayton Young, MD, FACOG, “OBGYN Against ACIP HPV Vaccine Decision,” 6/27/2006
64. CDC HPV Fact Sheet, http://www.cdc.gov/std/HPV/STDFact-HPV.htm
65. Merck Professional Privider Information Sheet: Gardasil® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recominant Vaccine. www.Merck.com
66. Daron G Ferris, “Facing the Future: The Impact of HPV Vaccination on Adolescent Health,” and “An Update of Clinical Trial Results With Preventative HPV Vaccines” http://www.medscape.com/viewprogram/5334
67. Merck Professional Privider Information Sheet: Gardasil® [Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recominant Vaccine. www.Merck.com

*Complied by Kathryn E. Rateliff, CCD, CCM, CCCE, GSM, PE, BFE
October, 1999 and most recently revised August 10, 2006



Parent/Guardian Signature ________________________________ Date ___________________


Witness ______________________________________________ Date ___________________

"It should be a rule in all prophylactic work that no harm should ever be unnecessarily inflicted on a healthy person (Sir Graham Wilson, The Hazards of Immunization, 1967)."
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I was going to go back through and check spelling...but this headache that has decided to creep up on me thinks it's a bad idea.



Child’s Name: _________________________

Parent’s/Guardian’s Name(s):__________________________________________ ___

My child’s health care provider, ______________________________ has advised me that my child (named above)
should receive the following vaccines:
Recommended Declined
[ ] [ ] Hepatitis B vaccine .
[ ] [ ] Diphtheria, Tetanus, a cellular Pertussis (DTaP) vaccine .
[ ] [ ] Diphtheria Tetanus (DT or dT) vaccine .
[ ] [ ] Haemophilus influenzae type b (Hib) vaccine .
[ ] [ ] Pneumococcal conjugate (PC) vaccine .
[ ] [ ] Polio vaccine (IPV) .
[ ] [ ] Measles, mumps, rubella (MMR) vaccine .
[ ] [ ] Varicella (chickenpox) vaccine .
[ ] [ ] Influenza (flu) vaccine .
[ ] [ ] Meningococcal vaccine .
[ ] [ ] Hepatitis A vaccine .
[ ] [ ] Other __________________________________________

I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s) explaining the vaccine(s) and the disease(s) they prevent. I have had the opportunity to discuss these with my child’s health care provider, who has answered all of my questions regarding the recommended vaccine(s). I understand the following

I haven't read the whole thing, but add a word like 'allegedly' or 'may' between the boldfaced words.
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#4 of 8 Old 02-04-2008, 06:07 PM
 
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Cara, I printed a similar form from a woman's website. Is that where you got the bulk of it from?

I am trying to determine what to put in mine but I think I am going to go simpler. I am basically going to state that it is not law to vaccinated in the state of California due to our exemptions (all three) and that vaccination is primarily required for school entry. I am going to state I understand that in the event of an outbreak that my child may be limited from attending school. I am also just going to say that I continue to do my research and have availed myself of every opportunity to discuss vaccines with my pediatrician (in my case, this is true) and that my pediatrician continues to discuss vaccination with me.

That's all I think. I just want the coercive language out. If the main intent is to reduce liability on the ped's part (it's a statement that he did discuss and offer vaccines), then that should be easy enough to get across. I just want mine to be short and simple... yes, got the info, yes, I am being informed/am informed, yes, i understand the repercussions (without listing each disease).
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Thank you mamas!
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That is excellent, and I admire all the hard work you put into it! My sister has a similar one that also outlines the religious reasons for not vaccinating.

I just hate the fact that we have to go through these kinds of things! Does anyone else feel like the government OWNS our children and we have to do our research and prove our points to be ALLOWED to raise them the way we want? That we have to get the government's PERMISSION to be EXCEMPT from raising our kids they way they want? Seriously, try to raise your kids your way without the government's permission, and see if your not harrassed at the least or have your kid's taken away at the worst.
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#7 of 8 Old 02-05-2008, 04:32 AM
 
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I am wondering where you live that you feel you need to convince anyone? In Washington, you can check one of three waiver boxes on the back of the immunization form for school - personal exemption, medical exemption, religious exemption - then sign, date, and you are done.

If there is an outbreak of something that your child hasn't been vaccinated for, I believe they'll try to make you keep your child home during that time. I have yet to see it happen to anyone, and you could likely fight it, but I'd just keep it short and sweet.

I claim personal exemption for my child, (child's name), regarding all vaccines (or list certain ones you don't do). Sign and date. Maybe it isn't that simple in other states?
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I am wondering where you live that you feel you need to convince anyone? In Washington, you can check one of three waiver boxes on the back of the immunization form for school - personal exemption, medical exemption, religious exemption - then sign, date, and you are done.

If there is an outbreak of something that your child hasn't been vaccinated for, I believe they'll try to make you keep your child home during that time. I have yet to see it happen to anyone, and you could likely fight it, but I'd just keep it short and sweet.

I claim personal exemption for my child, (child's name), regarding all vaccines (or list certain ones you don't do). Sign and date. Maybe it isn't that simple in other states?
My sister's midwife had to go through this to get her son into college. She lives in California and the college was in Nevada. They had to write up a lengthy letter detailing all the religious reasons complete with Bible verses, and the medical/scientific reasons. They had to take the letter up the chain of command, and fight to get him enrolled, even though he had already been accepted.
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