Professional Documents
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It is NOT recommended that Children and adults may be exempted from vaccinations for
medical, religious and/or philosophical reasons in all states,
children with the following excluding California, Mississippi and West Virginia, where
symptoms/conditions/histories only narrowly defined medical exemptions are permitted.
receive vaccines:
In New York, parents are required to submit a detailed
A current moderate or serious illnesswith or religious exemption statement describing the religious
principles that guide their objection to immunization.
without fever The principal or person in charge of their childrens school
A chronic health condition may require supporting documents and the school has
A weakened immune system, severe allergies or the authority to accept or reject the request for a
neurological disorders religious exemption.
A family history of neurological disorders,
severe allergies or immune system problems
A previous severe allergic reaction to a dose
of a vaccine or an ingredient in a vaccine (see
list of potentially toxic ingredients)
A family history of severe allergic reactions
to vaccines
Use this detailed chart to help keep track of your childs vaccine reaction history
Childs Name:
Childs Date of Birth: www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures,
Package Inserts) Age etc.) etc.) Skin Hardness/
Swelling, etc.)
DTaP: aluminum allergic reaction, 2 months:
hydroxide, brain damage (very ________ ________ ________ _____ ____________
Diphtheria, ________ ______
aluminum rare), erythema,
Tetanus, & potassium sulfate, fever, pain,
4 months:
Pertussis/ aluminum persistent ________ ______ ________ ________ ________ _____ ____________
Whooping phosphate, crying, poor 6 months
ammonium sulfate, ________ ________ ________ _____ ____________
Cough bovine extract,
appetite, redness/ ________ ______
(Brands: swelling, seizures, 12-18 months:
formaldehyde,
serious allergic
Daptacel, gelatin, g ________ ______ ________ ________ ________ _____ ____________
reaction, shock,
Infanrix) lutaraldehyde, 2-6 years:
peptone,
tiredness, vomiting.
________ ______ ________ ________ ________ _____ ____________
2-phenoxyethanol,
polysorbate 80, 7-18 years:
sodium chloride, ________ ______ ________ ________ ________ _____ ____________
sodium
phosphate,
thimerosal.
Hib: aluminum diarrhea, erythema, 2 months:
Haemophilus hydroxyphosphate fever, irritability, ________ ______ ________ ________ ________ _____ ____________
(in Hib/HepB loss of appetite,
Influenza Type B combo only), seizures,
4 months:
(Brands: ammonium sulfate, sleepiness, swelling, ________ ______ ________ ________ ________ _____ ____________
ACTHib, formaldehyde, tenderness, 12-18 months:
COMVAX, sodium chloride, vomiting. ________ ______ ________ ________ ________ _____ ____________
PedvaxHib) sucrose,
thimerosal.
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.
Brought to you by:
My Childs Vaccination Records (Contd.)
Childs Name:
www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures, Skin
Package Inserts) Age etc.) etc.) Hardness/
Swelling, etc.)
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.
Brought to you by:
My Childs Vaccination Records (Contd.)
Childs Name:
www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures, Skin
Package Inserts) Age etc.) etc.) Hardness/
Swelling, etc.)
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.
Brought to you by:
My Childs Vaccination Records (Contd.)
Childs Name:
www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures, Skin
Package Inserts) Age etc.) etc.) Hardness/
Swelling, etc.)
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.
Brought to you by:
My Childs Vaccination Records (Contd.)
Childs Name:
www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures, Skin
Package Inserts) Age etc.) etc.) Hardness/
Swelling, etc.)
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.
Brought to you by:
My Childs Vaccination Records (Contd.)
Childs Name:
www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures, Skin
Package Inserts) Age etc.) etc.) Hardness/
Swelling, etc.)
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.
Brought to you by:
My Childs Vaccination Records (Contd.)
Childs Name:
www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures, Skin
Package Inserts) Age etc.) etc.) Hardness/
Swelling, etc.)
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.
Brought to you by:
My Childs Vaccination Records (Contd.)
Childs Name:
www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures, Skin
Package Inserts) Age etc.) etc.) Hardness/
Swelling, etc.)
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.
Brought to you by:
My Childs Vaccination Records (Contd.)
Childs Name:
www.cmsri.org
Vaccine- Ingredients Potential Recommended Immunization Immunizer Injection Vaccine Lot My
Disease (Partial List Side Effects Immunization Date (Ex: Physician, Site Brand Name Number Childs
From (Partial List Age/ Pharmacist) (Ex: Right Leg, (Ex: Infantrix, (Ex: Reactions
Package Inserts) From Actual Left Arm, Recombivax, U1234AA) (Ex: Fever, Seizures, Skin
Package Inserts) Age etc.) etc.) Hardness/
Swelling, etc.)
Call a doctor immediately or go to an emergency room if your child shows symptoms of a serious vaccine reaction or experiences dramatic changes in physical, mental, or emotional behavior following a vaccination.