Fillable Certificate of Child Health Examination (Illinois)

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Certificate of Child Health Examination (Illinois)

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11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois
State of Illinois
Certificate of Child Health Examination
Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and
Maintained by the School Authority.
Student’s Name
Last First Middle
Birth Date
Month/Day/Year
Sex
Race/Ethnicity
School /Grade Level/ID#
Address Street City Zip Code
Parent/Guardian Telephone # Home Work
IMMUNIZATIONS: To be completed by health care provider. The mo/da/yr for every dose administered is required. If a specific vaccine is
medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health
examination explaining the medical reason for the contraindication.
DOSE 1
MO DA YR
DOSE 2
MO DA YR
DOSE 3
MO DA YR
DOSE 4
MO DA YR
DOSE 5
MO DA YR
DOSE 6
MO DA YR
DTP or DTaP
Pediatric DT (Check
specific type)
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
Polio (Check specific
type)
IPV
OPV
IPV
OPV
IPV
OPV
IPV
OPV
IPV
OPV
IPV
OPV
influenza type b
Conjugate
Hepatitis B
MMR Measles
Mumps. Rubella
Comments:
(Chickenpox)
RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose
Hepatitis A
HPV
Influenza
Immunization
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 here.
Signature Title Date
Signature Title Date
ALTERNATIVE PROOF OF IMMUNITY
1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach
copy of lab result.
*MEASLES (Rubeola) MO DA YR **MUMPS MO DA YR HEPATITIS B MO DA YR VARICELLA MO DA YR
2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.
Person signing below verifies that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as
documentation of disease.
Date of
Disease Signature Title
3. Laboratory Evidence of Immunity (check one) Measles* Mumps** Rubella Varicella Attach copy of lab result.
*All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.
**All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.
Completion of Alternatives 1 or
3 MUST be accompanied by Labs & Physician Signature: __________________________________________
Physician Statements of Immunity MUST be submitted to IDPH for review.
* indicates invalid dose
Birth Date
Sex
School
Grade Level/ ID
#
Last First Middle
Month/Day/ Year
HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
ALLERGIES
(Food,
drug, insect, other)
Yes
No
List:
MEDICATION
(Prescribed or
taken on a regula
r basis.)
Yes
No
List:
Diagnosis of asthma?
Child wakes during night coughing?
Yes No
Yes No
Loss of function of one of paired
organs? (eye/ear/kidney/testicle)
Yes No
Birth defects?
Yes No
Hospitalizations?
When? What for?
Yes No
Developmental delay?
Yes No
Blood disorders? Hemophilia,
Sickle Cell, Other? Explain.
Yes No
Surgery? (List all.)
When? What for?
Yes No
Diabetes?
Yes No
Serious injury or illness?
Yes No
Head injury/Concussion/Passed out?
Yes No
TB skin test positive (past/present)?
Yes* No
*If yes, refer to local health
department.
Seizures? What are they like?
Yes No
TB disease (past or present)?
Yes* No
Heart problem/Shortness of breath?
Yes No
Tobacco use (type, frequency)?
Yes No
Heart murmur/High blood pressure?
Yes No
Alcohol/Drug use?
Yes No
Dizziness or chest pain with
exercise?
Yes No
Family history of sudden death
before age 50? (Cause?)
Yes No
Eye/Vision problems? _____ Glasses
Contacts
Last exam by eye doctor ______
Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Dental
Braces
Bridge
Plate Other
Ear/Hearing problems?
Yes No
Information may be shared with appropriate personnel for health and educational purposes.
Parent
/Guardian
Signature
Date
Bone/Joint problem/injury/scoliosis?
Yes No
PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA
HEAD CIRCUMFERENCE
if < 2-3 years old HEIGHT WEIGHT BMI BMI PERCENTILE
B/P
DIABETES SCREENING
(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 Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No
LEAD RISK QUESTIONNAIRE: Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school
and/or kindergarten.
(Blood test required if resides in Chicago or high risk zip code.)
Questionnaire Administered
? Yes No Blood Test Indicated? Yes No Blood Test Date Result
TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born
in
high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. http://www.cdc.gov/tb/publications/factsheets/testing/TB_testing.htm.
No test needed
Test performed Skin Test: Date Read / / Result: Positive Negative mm__________
Blood Test: Date Reported / / Result: Positive Negative Value
LAB TESTS (Recommended)
Date Results
Date Results
Hemoglobin or Hematocrit
Sickle Cell (when indicated)
Urinalysis
Developmental Screening Tool
SYSTEM REVIEW
Normal
Comments/Follow
-up/Needs
Normal
Comments/Follow
-up/Needs
Skin
Endocrine
Ears
Screening Result:
Gastrointestinal
Eyes
Screening Result:
Genito-Urinary
LMP
Nose
Neurological
Throat
Musculoskeletal
Mouth/Dental
Spinal Exam
Cardiovasc
ular/HTN
Nutritional status
Respiratory
Diagnosis of Asthma
Mental Health
Currently Prescribed Asthma Medication:
Quick-relief medication (e.g. Short Acting Beta Agonist)
Controller medication (e.g. inhaled corticosteroid)
Other
NEEDS/MODIFICATIONS required in the school setting
DIETARY Needs/Restrictions
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup
MENTAL HEALTH/OTHER Is there anything else the school should know about this student?
If you would like to discuss this student’s health with school or school health personnel, check title: Nurse Teacher Counselor Principal
EMERGENCY ACTION
needed while at school due to child’s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)?
Yes No If yes, please describe.
On the basis of the examination on this day, I approve this child’s participation in (If No or Modified please attach explanation.)
PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Modified
Print Name (MD,DO, APN, PA) Signature Date
Address
Phone
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Certificate of Child Health Examination (Illinois)

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Completed 9 August 2021

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