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Patient Name_______________________________ Birthdate_______________ As the parent/guardian of __________________________, I have investigated the risks and benefits of the following vaccines and diseases. I am aware that there are documented cases of people contracting diseases for which they are clinically fully immunized and that the manufacturers of the vaccines do not guarantee 100% efficacy. I am also aware that VAERS (Vaccine Adverse Events Reporting System) documented cases of over 54,000 adverse reactions from vaccines in a 20-month period.
The National Vaccine Injury Fund, created in 1986 to compensate those damaged by vaccines has paid out over one billion dollars in compensation to date.

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.

RUBEOLA (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 rubeola. 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
es/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, teething, 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, monisodium 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 formal

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)

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;

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;

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"
Complied by Kathryn E. Rateliff, CCD, CCCE, SM October, 1999 and revised January, 2001

Questions and comments can be addressed to her at:

Want to know more about the issue of vaccine choice? Titus 2 Birthing has a 42-page packet to help parents look at some of the issues regarding vaccine choice. This packet includes the above form plus many other helpful documents. Topics include: vaccine safety, disease frequency in the US, exemption information and worksheet, religious concerns about vaccines, immunization registry information, vaccinations and premature babies, vaccines and immune supression, the American Association of Physicians and Surgeons policy on mandatory vaccines, additional resources, and Jock Doubleday's challenge for immunization providers to drink a vaccine additive cocktail. If you are interested in getting a copy of this packet, contact Kathy at the above email address and she will be glad give you all of the details. Note that there is a cost for this packet.

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