State of Illinois ID)C]FSLB

I
State of
[fnH$
cFS 600
R6v12/20i,
Certificate of Child Health Examination
Studcnt's Namc
Birth Drtc
Lat
Firsr
Address
FOR USE IN DCFS LICENSED CHILD CARE FACILITIES
Illinois
Middle
Citu
Street
Rrce/Ethnicity
Sex
ID)C]FSLB
School /Gmde LevcUID#
MontVDay/Year
Tiaarle
_!gg!!Qg!4!im
Tctephonc
#
iloru
Worl
IMMUNIZATIONS:
To be completed by health care provider. Note the mo/dalyr for every dose administered. The day and month is required if you cannot
determine ifthe vaccine was given after the minimum interval or age. If r spccific vrccine is mcdically contrrindicrted, r seporrtc writtin sratement
must be
rttachcd expleining thc medical reason for thc contmindicrtion,
Vaccinc / Dosc
I
MO DAYR
2
J
MO DAYR
4
5
MO DA YR
MO DAYR
6
MO DAYR
MO DAYR
trTdaptrTdtrDT
trTdaptrTdtrDT
trTdaptrTdtrDT
uTdaptrTdtrDT
trTdaptrTdtrDT
DTP or DTaP
Tdap; Td or Pediatric
DT (Check spccific type)
tr IPV tr OPV
Polio (Check specific
tvpe)
Hib
tr IPV tr
tr
OPV
tr
IPV tr OPV
IPV tr
tr
OPV
trTdaptrTdtrDT
tr rPv tr oPv
rPv tr oPv
Haemophilus
influenza type b
Heprtitis B (HB)
Vrricelle
COMMENTS:
(Chickenpox)
MMR
Combined
Measles Mumps. Rubella
Rubella
Measles
Singlc Antigcn
Mumps
Vaccines
Pneumococcal
Conjugate
Othcr/Specify
Meningococcal, .
Hepatitis A, HPV,
Influenza
Herlth crrc providcr (MD, DO, APN, PA, school hcalth profcssional, health oflicirl) verifying abovc immunization history must sign below. If adding dates
to the above immunization history sectiorl put your initials by date(s) and sign here.)
Signature
Title
Date
Signature
Title
Date
ALTERNATIVE PROOF OF IMMUNITY
l. Clinicrl dirgnosis
is rcccptsbtc if verified by
physicirn
r(All meules cres
diagnoscd on or after July
l,
2002,
mut
U"
"ont-"Jty
t"tootory
*ia..o.1
*MEASLES (Rubcolr) uo oe vn MUMPS Mo DA yR VARICELLA Mo DA yR
Phvsician's Sisnrturc
2. History ofvaricclh (chickcnpox) discasc is rcceptablc ifverified by herlth care provider, school health profcssionel or t ealin omciaL
Signeturc
Da0c of Diseesc
3, Laborrtory conlirmetion (check onc)
Tidc
EMumps
EMeasles
Lab Results
Deta
MO
DA
Dstc
ERubella
EHepatitis
B
EVaricella
(Attsch copy of lab result)
YR
VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TE,CHNICIAN
Datc
Codcl
ASEI
P=Pas
Gradc
RL
RL
R
L
R
L
RL
R
L
Vision
R
L
R
L
F = Fail
U = Uneblc
R = Rcfcrred
G/C=
Gl8!B/Contrcts
Hcrring
tL444-4737 (R-01-r2)
RL
(C0MPLETE BOTH SIDES)
Printed by Authority of tbc State of lllinois
'-
Birth Date
-st
First
HEALTII
IIISTORY
ALLERGIES
(F@d, drus,
Middlo
icr
ichool
lrrdc
!IEDICATION
(List all pr€$ribed o. taken on e rcgulu basis)
Yes
Yes
No
No
Loss offunction ofone ofpaired
organs? (eyelearlkidneyi testicle)
fes
No
Birth defects?
Yes
No
No
Yes
No
Hospitalizations?
When? What for?
fes
Developmental delay?
Blood disorders? Hemophil i4
Sickle Cell. Other? Explain.
Yes
No
Surgery? (List all.)
When? What for?
fes
No
Yes
No
Serious injury or illness?
fes
No
Yes
No
TB skin test positive (pasVpresent)?
No
Seizures? What are they like?
Yes
No
TB disease (past or present)?
Yest
Yesr
No
Heart problem/Shortness of breath?
Yes
No
'I
Yes
No
Heart murmur/High blood pressure?
Yes
No
AlcohoUDrug use?
Yes
No
Dizziness or chest pain with
exercise?
Yes
NO
Family hislory ofsudden death
before age 50? (Cause?)
Yes
No
Diabetes?
Head injury/Concussior/Passed
_
out?
E
Classes
Cotrracts
Bone/Joint problem/injury/scoliosis?
fes
if
< 2-3
yers
ilf
yes, refer to local hmlth
d€partment.
Other
Information may be shued with approp.iate p.r"onniifoilrcalG md
ParcnUGuardian
No
PHYSICAL EXAMINATION REQUIREMENTS
obacco use (type, fiequency)?
Dental EBraces D.Bridge tr.Plate
E Lastexambyeyedoctor_
Other concems? (cmssed eve- droonino lidc souintino difficrrlt reedinol
Ear/Hearing problems?
/es
No
HEAD CIRCUMFERENCE
lf
TO Bf, COMPLf,,Tf,,D AND STGNED BY PARENT/GUARDIAN AND Vf,RIFIED BY ITEALTII
CARE PROVIDER
imer, other)
Diagnosis of asthma?
Child wakes during night coughing?
EyelVisionproblems?
LeveU
MontvDsy/ Yeu
edEGiIJfrE
iignaturc
Dete
Entire sectiod bctow to be completed by MD/DO/ApN/pA
HEIGHT
old
WEIGHT
BMI
BI?
)IABETESSCREENING lnoTnEQU|RED FoR DAY CARE) BMbES% age/sex YeslJ Notr And any two of the following: Frrinily Hisrory yes E No tr
0thnic Minority YesE No tr Signs of Insulin Resistancc Oypert€nsion, dyslipidemia, polycystic ovarian syndromc, acmthosis nigrica*j yestr tio tr ai nist yes E No
LEADRIsKQUESTIoNNAlRERequiredforchildrenage6monthsthrough6yiars
md/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.)
Blood Test Indicrtcd? Yes E No
Questionnsirc Administered ? Yes E No E
E
Btood Test
Date
E
Result
tBSKINoRBLooDTESTRecomendedonlyforchildrcninhigh.riskgroupsincludingchiIdreni
n high prevalencc coutries or those exposcd to adults in high-risk categorics. See CDC
Skin Test: Date Rerd
Blood Tesli Date Reported
LAB TESTS
E
Rcsulh Positive E
Result: Positive
I
(ntcommnd.d)
Date
0
guidelines. No tcst needed
Negative E
Negativc E
Test pcrformed
E
mm
Valuc
Results
Date
Hemoglobin or Hematocrit
Results
iickle Cell (when indicated)
Urinalvsis
)evelopmental Screenine Tool
SYSTEM REVIEW
Skin
tlormrl lomments/Follow-upAIceds
t{ormel lomments/Foltow-up/I{eeds
Endocrine
Ears
Gasirointestinal
Eycs
Amblyopia YesE NoB
Gcnito-Urinary
Nosc
LMP
Neurologicel
Throat
Musculoskeletrl
Mouth/Dentrl
Spinrl Exam
Cardiovesculer/IITN
Nutritional stetus
E
Respiratory
Diagnosis of Asthma
Mentel Herlth
Cunently Prescribed Asthma Medication:
D Quick+elief medication (e.g. Short Acting Beta Agonist)
Othcr
E Controller medication (e.g. inhaled corticosteroid)
NEEDS/MODIFICATIONS
DIETARY
rcquircd in the school setting
SPECIAL INSTRUCTIONS/DEVICES
e.g. safety glmses,
glxs
Needs/Resbictiom
eye, chest protector for anhythmia, pacema.ker,
MENTAL HEALTWOTHER Is therc mything else the schml should know about this student?
If you would like to discuss this student's health with school or school health penomel, check
EI Nme
titlc:
prstnetb aivice, dental bridge, fulr" t""th3thl"ti*ppo.u"rp
E Teacher E Comselor E hincipal
EMERGENCY ACTION
Yes
tr No tr
needed while at school due to child's health condition (e.g. ,seiroes, asthm4 imect sting, fmd, pemut aliergy,
lfyes, please describo.
On the basis of the emination on this day, I approve this child's participation in
PHISICAL EDUCATION Yes tr No
Print Namc
Addrcss
tr
(lf No or Modified pleree
Modified tr
INTERSCHOLASTIC SPORTS
(MD,DO, APN,
PA)
Sisnarure
lhonc
(Complete Both Sides)
bl";di"g pr"bl"-, di"b"t*, h"rrr prcblem)?
attach explamtion.)
Yes
['I
No
l-l
Drtc
l.imited I-l
lllinois Department of Public Health
PROOF OF SCHOOL DENTAL EXAMINATTON FORM
To be completed by the parent (please print):
Student's
Name:
Address:
Last
First
Street
Middle
City
Birth Date: (trmovoay/y<f
tt
ZIP Code
Name of Sctrool:
Telephone:
Grade Level:
Gendec
U
Parent or Guardian:
Male D Female
Address (of parenUguardian):
To be completed by dentist:
Oral Health Status (check all that apply)
tl Yes O No
O
Yes
Dental Sealants Present
tl No Caries Experience
/ Restoration History
exkacted as a resuh of caries OR n{sshg pernranent
B Yes trl No Untreated Garies
-
A filling (temporary/permanent)
oR a tooth that is missing because it was
1sr rnolars-
At leasl 1f2 mm of tooth structure loss at the enamel surface. Brown lo dark-brorvn coloration d the
walls of lhe lesion. These oiteria apply to grit and fissure cavitated lesions as wetl as those oo smoolh iooth surfiaces. lf retained
rco( assume that tfie wftole tooth was destoyed by caries. Broken or cfripped teeth, plus teeth with temporary fillings, ar€ consllered sound trnless a cavilated lesion is also pesent.
D Yes
O
-
tl No Soft Tissue Pathology
Yes O No Malocclusion
Treatment Needs (check all that apply)
tr Urgent Treatment
CI Restorative
tl Preventive
E Other
-
Gare
Care
-
-
abscess, nerve exposure, advanced diseas€ state. signs or synplotrs that indude pain, infec{ion. or swelling
amalgams, cornposites, croi,ns, etc.
sealants. ffuoride keabnen( prophy{axis
periodontal, orthodontic
Please note
Signature of Dentist
Date
Address
Telephone
Clty
lllinois Department of Public Health, Division of Oral Health, 535 W. Jefferson SL, Springfield, lL 62761
211-7854899 ' TTY (hearing impaired use only) 800-S7{466 . www.idph.state.il.us
Prhted by Aurhority of trte State of lllinois
P.O-#346085
5M
10/05