Fillable Printable Certificate of Child Health Examination - Illinois
Fillable Printable Certificate of Child Health Examination - Illinois
Certificate of Child Health Examination - Illinois
State of Illinois
Certificate of Child Health Examination
IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) P r inted by Aut hority of the S ta te of I l linois
Student’s Na me
Last First Midd le
Birth Date
Month/Day/Year
Sex
Race/Ethnicity
School /Grade Level /ID#
Address Street City Zip Code
Parent/Guardian Telepho ne # Home Work
IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot
d eterm in e if the vaccine wa s giv en after the m inimum int erv al or ag e. If a specific vaccine is medically contraindicated, a separate written statement must be
attached explaining the me dical reason for the contrai ndic ation.
Vacc in e / Dos e
1
M O DA YR
2
M O DA YR
3
MO DA YR
4
M O DA YR
5
M O DA YR
6
MO DA YR
DTP or DTaP
Tdap; Td or P ediatric
DT (
Check specific type)
TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT
Polio (Check specifi c
type)
IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV
Hib Haemophilus
influenza type b
Hep at itis B (HB)
Varicella
(Chickenpox)
COMMENTS:
MMR Combined
Measles Mumps. Rubella
Single Antigen
Vaccines
Measles Rubella Mumps
Pneumococcal
Conjugate
Other/Specify
Meningococcal,
Hepa titis A, HPV,
Influenza
Health care provider (MD, DO, APN, PA, school health professional , health official) verifying above immunization history must sign below. If adding dates
to the above immunization history section, put your initials by date(s) and sign h ere.)
Signature Title Date
Signature Title Date
ALTERNATIVE PROOF OF IMMUNITY
1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2 002, must be confir med by laborator y e vidence.)
*MEASLES (Rubeola)
MO DA YR
MUMPS
MO DA YR
VARICE LLA
MO DA YR
Phy sician’s Sig nature
2. History of vari cella (chickenpox) disease is acceptable if verified by health ca re provider, school health professio nal or health official.
Person signing be low is verifying that the parent/guardian’s descriptio n of varice lla d isease his to ry is indicative of past infect io n and is accepting suc h history as docu mentation of disease.
Date of Disease Signature Title Date
3. Laboratory confirmation (check one)
Measles Mumps Rubella Hepatiti s B Varicella
Lab Results Date MO DA YR (Atta ch copy of lab result)
VISIO N AND H EARING SCREENI NG BY IDPH CERTIFI ED SCREENI NG TECHNICIAN
Date
Code:
P = Pass
F = Fail
U = Unable to test
R = Referred
G/C =
Glasses/Contacts
Age/
Grade
R L R L R L R L R L R L R L R L R L
Vision
Hearing
FOR USE IN DCFS LICENSED CHILD CARE FAC ILITIES
CFS 600
Rev 2/2013
Bi rth Date
Sex
School
Grade Level/ ID
#
Last First Middl e
Month/Day/ Year
HE ALTH HISTORY TO BE COMP LETED AND SIGNED BY PARENT/G UARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
ALLERGIES
(Food, drug, insect, ot her)
MEDI CATION (
List all pr escribed or t aken o n a regular basis.)
Di agnosis of asthma?
Chi l d wakes d uring n ight coughing ?
Yes No
Yes No
Loss of function of one of paired
orga ns? (e ye/ear/kidney/ testicle)
Yes No
Birth defects?
Yes No
Hospitalizations?
When? What for?
Yes No
Developmental delay?
Yes No
B lood disorders? Hemophili a,
Sick le Cell, Other? Ex pla in.
Yes No
Sur gery? (Li st all. )
When? What for?
Yes No
Diabetes?
Yes No
Se rious injury or illness?
Yes No
Head injury/Concussion/Passed out?
Yes No
TB sk i n test po sitiv e (past/ pr esen t) ?
Yes* No
*If ye s, r efer to local health
department.
Seizu r es? Wha t a r e t hey like?
Yes No
TB di se ase ( past or pr esent ) ?
Yes* No
Heart problem/Shortness of breath?
Yes No
Tobacco use (type, frequency)?
Yes No
Heart murmur/High blood pressure?
Yes No
Alcohol/Dr ug use?
Yes No
Dizziness or c hest pain with
exercise?
Yes No
Family history of su d den dea t h
before age 50? (Cause?)
Yes No
Eye/Vision problems? _____
Glasses Contacts Last exam by eye doctor ______
Other concerns? (crossed e ye, drooping lids, squinting, difficulty reading)
Dental
B r aces
B r id g e
Plate Other
Ear/Hearing problems?
Yes No
Information may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
Signatur e Date
Bone/Joint problem/injury/scoliosis?
Yes No
PHYSICAL E XAM INAT ION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA
HEAD CIRCUMFERE NCE if < 2-3 year s old HEIGHT WEI GHT BMI
B/P
DIAB ETES SCREENI NG ( NOT REQUIRED FOR DAY CARE) BMI
>
85% age/sex Yes No And any two of the following: Family History Yes No
Ethnic Minority Yes No Signs of Insuli n Resistance (hypertension, dyslipidemi a, pol ycys tic ovarian s yndrome , a ca nthosis nigr icans) Yes No At Risk Yes No
LEAD RISK QUESTI ONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school
an d/or ki nderga r ten. (B lood test requi red if res i des in Chicago or high risk zip code.)
Questionnaire Administered ? Yes No Bloo d Tes t I ndicated? Yes No Blood Test Da te Result
TB SKIN OR BLOOD TEST
Recomme nde d o nly for c hildren in high-r is k group s includi n g children immunosuppressed due to HIV infect ion or ot her conditions, fre quent trave l to or born
in high pre va lence co untries or those e xpose d to adults in high-risk cate gories . See CDC guidelines .
No test needed Test performed
Skin Test: Date Read / / Result: Positive Negative mm ______________
Blood Test : Date Reported / / Res u lt: Positive
Negative
V alu e ______________
LAB TESTS (Recommended)
Date Results
Date Results
Hemogl obin or Hema tocrit Sickle Cel l (when ind i cated)
Urinalysis
Developmental Screen i ng Tool
SYSTEM REVIEW Normal Comments/Follow-up/Needs
Normal Comments/Follow-up/Needs
Skin
Endocrine
Ears
Gastrointestinal
Eyes
Amb lyopia Y es No
Genito-Urinary
LMP
Nose
Neurological
Throat
Musculoskeletal
Mouth/Dental
Spinal Exam
Cardiovascular/HTN
Nutritional status
Respiratory
Diagnosis of Ast hma
Me n tal Health
C ur rentl y Pr escr ibed Asthma Medication:
Quick-relief medication (e.g. Short Acting Beta Agonist)
Controller medicati on (e.g. inhaled corticosteroid )
Other
NEEDS/MODIFICATIONS
required in the school setting
DIETARY
Needs/Restrictions
SPECIAL INSTRUCTIONS/DEVICES e. g. safety glasses, glass eye, ches t protector for arrhythmia, pacemaker, prost hetic device, dental bridge, false teeth, athleti c support/cup
MENTAL HEALTH/OTHER
Is there anything else the schoo l sho uld know a bout this stude nt?
If you wo uld like to disc uss this student’ s he alth with sc hool o r s chool health person n el, chec k tit le: Nurse Teacher Counselor Principal
EM ERGE NCY ACTION
needed while at sc hool due to child’s health condition (e. g. ,seizures, asthma, insect st ing, food, peanut alle r gy, bleeding prob lem, diabetes, heart proble m)?
Yes No If yes, please describe.
On the basis of the e xa minatio n on this day, I approve this child’s partic ipation in (If No or Modified please attach explanat ion.)
PHYSICAL EDUCATION Yes No Modified INTERSCH OLASTIC SPORTS Yes No Limited
P r int Name (MD,DO, APN, PA) Signature Date
Address
Phone
(Co mplet e Both Sides)
