State of Illinois Certificate of Child Health Examination
attached explaining the medical reason for the contraindication. Vaccine / Dose 1 MO DA YR 2 MO DA YR 3 MO DA YR 4 MO DA YR 5 MO DA YR 6 MO DA YR DTP or DTaP Tdap; Td or Pediatric DT (Check specific type) Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Polio (Check specific type) ................
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