Child General Health Form

Sleep: Your health care provider recommends all infants less than 1 year of age be placed on their back for sleep.

Health care provider

OR

COLORADO DEPARMENT OF PUBLIC HEALTH AND ENVIROMENT--- CERTIFICATE OF IMMUNIZATION

Vaccine Enter the month, day and year each immunization was given
Hep B Hepatitis B
DTap Dephtheria, Tetanus, Pertussis (pediatric)
DT Dephtheria, Tetanus (pediatric)
Tdap Tetanus, Dephtheria, Pertussis
Td Tetanus, Dephtheria/td>
Hib Haemophilus, influenzae type b
IPV/OPV Polio
PCV Pneumococcal, Conjugate
MMR Measles, Mumps, Rubella
Varicella Chickenpox
Vaccine recorded below this line are recommended. Recording of dates is encouraged.
HPV Human Papillomavirus
Rota Rotavirus
MCV4/MPSV4 Meningococcal
Hep A Hepatitis A
TIV/LAIV Influenza
Other

This Section Can Be Completed By Child Care/School/Health Care Provider

*If age 4 years and fulfils Requirements for Pre-School & Kindergarden, check BOTH Boxes C and D.

Has Meet All Immunization Requirements For Colorado Schools (6th Grade or Higher)

(Physician, nurse, or school health authority)

Statement Of Exemption To Immunization Law (Declaraion Respecto A LAS Exenciones De La Ley Vacunacion)

IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONSMAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE.

SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LAS PONGA EN CUARENTENA O SE LES EXCLUYA DE LA ESCUELA.

MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medically contraindicated due to other medical conditions.
EXENCIÓN MÉDICA: La condición física de la persona mencionada anteriormente es tal que la inmunización podría poner en peligro la vida o la salud o está médicamente contraindicada debido a otras afecciones médicas.

Physician (Medico)
Exención médica para la(s) siguiente(s) vacuna(s):

RELIGIOUS EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed to immunizations.
EXENCIÓN RELIGIOSA: El padre o tutor de la persona mencionada anteriormente o la persona misma es un adherente a una creencia religiosa opuesta a las vacunas.

Parent, guardian, emancipated student/ conseling minor
(Padre, tutor, estudiante emancipado / menor consagrado)
Exención religiosa a la(s) siguiente(s) vacuna(s):

PERSONAL EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed to immunizations.
EXENCIÓN PERSONAL: El padre o tutor de la persona mencionada anteriormente o la persona misma es un adherente a una creencia personal opuesta a las vacunas.

Parent, guardian, emancipated student/ conseling minor
(Padre, tutor, estudiante emancipado / menor consagrado)
Exención personal a la(s) siguiente(s) vacuna(s):

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