Illinois Child Health Examination Form – Fill Out and Use This PDF

Immunizations are to be completed by the health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication.

A health care provider (MD, DO, APN, PA, school health professional, health official) verifying the immunization history must sign, with Signature, Title and Date. If adding dates to the immunization history section, the health care provider must put initials by the date(s) and sign. For alternative proof of immunity: 1. Clinical diagnosis is acceptable if verified by physician. (All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) Measles (Rubeola), Mumps and Varicella each have a MO DA YR, with the Physician's Signature. 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. The person signing is verifying that the parent/guardian's description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Write the Date of Disease, Signature, Title and Date.

For laboratory confirmation, check one: Measles, Mumps, Rubella, Hepatitis B or Varicella. Write the Lab Results Date (MO DA YR). Attach copy of lab result.

Vision and hearing screening is by an IDPH certified screening technician. Code: P = Pass, F = Fail, U = Unable to test, R = Referred, G/C = Glasses/Contacts.

Health history is to be completed and signed by parent/guardian and verified by health care provider. List allergies (food, drug, insect, other). Medication: list all prescribed or taken on a regular basis.

The entire physical examination requirements section is to be completed by MD/DO/APN/PA: head circumference, height, weight, BMI and B/P. Diabetes screening is not required for day care. For diabetes screening, Yes or No for BMI>85% age/sex and any two of the following, Yes or No for each: Family History, Ethnic Minority, Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans); At Risk, Yes or No. The lead risk questionnaire is required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten.

TB skin or blood test is 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.

If you would like to discuss this student's health with school or school health personnel, check title: Nurse, Teacher, Counselor or Principal. Emergency action needed while at school due to the child's health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes or No. If yes, please describe.

Approve this child's participation in physical education (Yes, No or Modified) and interscholastic sports for one year (Yes, No or Limited). If No or Modified, please attach explanation. Print name (MD, DO, APN, PA), signature, date, address and phone.