Fillable Printable Universal Health Certificate - District of Columbia
Fillable Printable Universal Health Certificate - District of Columbia
Universal Health Certificate - District of Columbia
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Part 1: Child’s Personal Information Parent/Guardian: Please complete Part 1 clearly and completely & sign Part 5 below.
Child’s Last Name: Child’s First & Middle Name: Date of Birth:
Gender:
M
F
Race/Ethnicity:
White Non Hispanic
Black Non Hispanic
Hispanic
Asian or Pacific Islander
Other______________
Parent or Guardian Name: Telephone:
Home
Cell
Work
Home Address:
Ward:
Emergency Contact Person: Emergency Number:
Home
Cell
Work
City/State (if other than D.C.)
Zip code:
School or Child Care Facility:
Medicaid
Private Insurance
None
Other ________________________________
Primary Care Provider (PCP):
Part 2: Child’s Health History, Examination & Recommendation s Health Provider: Form must be fully completed.
DATE OF HEALTH EXAM: WT LBS
KG
HT IN
CM
BP:
(>3 yrs)
NML
ABNL
Body Mass Index
(>2 yrs)
(BMI)___________
%______________
HGB / HCT
(Required for Head Start)
Vision Screening
Right 20/____ Left 20/____
Glasses
Referred
Hearing Screening
Pass________ Fail________ Referred
HEALTH CONCERNS: REFERRED or TREATED HEALTH CONCERNS: REFERRED or TREATED
Asthma
NO
YES
Referred Under Rx
Language/Speech
NONE
YES Referred Under Rx
Seizure
NO
YES
Referred Under Rx
Development/
Behavioral
NONE
YES Referred Under Rx
Diabetes
NO
YES
Referred Under Rx
Other____________
NONE
YES Referred Under Rx
ANNUAL DENTIST VISIT: (Age 3 and older): Has the child seen a Dentist/Dental Provider within the last year? YES NO Referred
A. Significant health history, conditions, communicable illness, or restrictions that may affect school, child care, sports, or camp.
NONE YES, please detail:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
B. Significant food/medication/environmental allergies that may require emergency medical car e at school, child care, camp , or
sports activity.
NONE YES, please detail: _________ __________________________________________________________________________
_____________________________________________________________________________________________________________
C. Long-term medications, over-the-counter-drugs (OTC) or special care requirements.
NONE YES, please detail (
For any medications or treatment required during school hours, a Physician’s Medicati on Authorization Order
should be submitted with this form)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Part 3: Tuberculosis & Lead Exp osure Risk Assessment & Testing:
TB RISK ASSESSMENTS
HIGHÆ
LOW
Tuberculin Skin Test
(TST) DATE:
NEGATIVE
POSITIVE
If TST Positive
CXR NEGATIVE
CXR POSITIVE
TREATED
Health Provider: PO SITIVE TS T
should be referred to PCP f or
evaluation. For questions, call T.B.
Control: 202-698-4040
LEAD EXPOSURE RISKS
YE SÆ
NO
LEAD TEST DATE:
RESULT:
Health Provider: ALL lead levels must be reported to DC Childhood Lead
Poisoning Prevention Program:
Fax: 202-481-3770
Part 4: Require d Provider Certification and Signature
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__________________________________________________________________
Print Name
MD/NP Signature Date
Address Phone Fax
Part 5: Require d Parental/Guardian Signatures. (Release of Health Information)
I give permission to the signing health examiner/facility to share the health information on this form with my child’ s school, child care, camp, or appropriate DC Government Agency.
Print Name Signature Date
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Student’s Name: __________________________ __/_________________________/________________ Date of Birth:_____/_____/________
Last First Middle Mo. /Day/ Yr.
Sex:
Male Female School or Child Care Facility:______________________________________________________________
Section 1: Immunization: Please fill in or attach equivalent copy with provider signature and date.
IMMUNIZATIONS RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN
Diphtheria,Tetanus, Pertussis (DTP,DTaP)
1 2 3 4 5
DT (<7 yrs.)/ Td (>7 yrs.)
1 2 3 4 5
Tdap Booster
1
Haemophilus influenza Type b (Hib )
1 2 3 4
Hepatitis B (HepB)
1 2 3 4
Polio (IPV, OPV)
1 2 3 4
Measles, Mumps, Rubella (MMR)
1 2
Measles
1 2
Mumps
1 2
Rubella
1 2
Varicella
1 2
Chicken Po x Disea s e History: Yes
When: Month____________ Year___________
Verified by:___________________________________________ (Health Care Provider)
Name & Title
Pneumococcal Conjugate
1 2 3 4
Hepatitis A (HepA) (Born on or after 01/01/2005)
1 2
Meningococcal Vaccine
1
Human Papillomavirus (HPV)
1 2 3
Influenza (Recommended)
1 2 3 4 5 6 7
Rotavirus (Recommended)
1 2 3
Other
_______________________________________________ ______ _________________________________ __________
Signature of Medical Provider Print Name or Stamp Date
Section 2: MEDICAL EXEMPTION. For Health Care Provider Use Only.
I certify that the above student has a valid medical contraindication to being immunized at the time against: (check all that apply)
Diphtheria: (__) Tetanus: (__) Pertussis: (__) Hib: (__) HepB: (__) Polio: (__) Measles: (__) Mumps: (__) Rubella: (__) Varicella: (__) Pneumococcal: (__)
HepA: (__) Meningococcal: (__) HPV: (__)
Reason:________________________________________________________________________________________________________________________
This is a permanent condition (___) or temporary condition (___) until ____/____/____.
_______________________________________________ ___________________ ____________________ __________
Signature of Medical Provider Print Name or Stamp Date
Section 3: Alternative Proof of Immuni ty. To be completed by Health Care Provider or Health Official.
I certify that the student named above has laboratory evidence of immunity: (Check all that apply & attach a copy of titer results)
Diphtheria: (__) Tetanus: (__) Pertussis: (__) Hib: (__) HepB: (__) Polio: (__) Measles: (__) Mumps: (__) Rubella: (__) Varicella: (__) Pneumococcal: (__)
HepA: (__) Meningococcal: (__) HPV: (__)
_______________________________________________ _________________ ______________________ _____ _____
Signature of Medical Provider Print Name or Stamp Date
