DHS Form CFS 600 is a critical document for any individual or family working with the Department of Human Services. The form must be completed and submitted in order to receive benefits and assistance from DHS. Completing the form accurately is essential, as it provides information about your family's situation and needs. The DHS website provides detailed instructions on how to complete the form, so be sure to review them before starting the process. Thankfully, the online fillable version of the form makes submitting it a breeze. Be sure to submit your CFS 600 as soon as possible to get started on receiving the help you need.
| Question | Answer |
|---|---|
| Form Name | Dhs Form Cfs 600 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Inactivated, cfs600 form, CDC, ILLINOIS |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
FOR USE IN DCFS LICENSED CHILD CARE FACILITIES |
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
CFS 600 |
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
REV 5/2006 |
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
STATE OF ILLINOIS |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
DEPARTMENT OF HUMAN SERVICES |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
Please Print |
|
|
|
CERTIFICATE OF CHILD HEALTH EXAMINATION |
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Student’s Name Last |
First |
|
Middle |
|
|
|
Birth Date |
|
Sex |
|
Grade Level |
|
ID# |
|
|
|
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Parent/ |
|
|
|
|
|
|
|
|
Telephone # |
|
|
|
|
|
|
|
|
|||
Address |
Street |
City |
|
|
ZIP code |
|
Guardian |
|
|
|
|
|
|
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 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. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
1 |
|
|
|
|
|
2 |
|
|
3 |
|
|
|
4 |
|
|
5 |
|
|
|
6 |
|
|
||||
|
VACCINE/DOSE |
|
MO DA |
|
YR |
|
MO |
|
DA |
|
YR |
MO DA |
|
YR |
|
MO DA |
|
YR |
MO DA |
|
|
YR |
MO DA |
|
YR |
||||
Diphtheria, Tetanus and Pertussis |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(DTP or DTaP) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Diphtheria and Tetanus (Pediatric DT or Td) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Inactivated Polio (IPV) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Oral Polio (OPV) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Haemophilus influenzae type b (Hib) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Hepatitis B (HB) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Varicella (Chickenpox) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Comments |
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Combined Measles, Mumps and Rubella (MMR) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Measles (Rubeola) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Rubella |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Mumps |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
Pneumococcal (not required for school entry) |
PCV7 |
PPV23 |
|
PCV7 |
PPV23 |
PCV7 |
PPV23 |
|
PCV7 |
PPV23 |
PCV7 |
PPV23 |
PCV7 |
PPV23 |
|||||||||||||||
Check specific type (PCV7, PPV23) |
Date |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Other (Specify hepatitis A, meningococcal, etc.) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below.
|
Signature |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Title |
|
|
|
|
|
|
|
Date |
|
||||
|
Signature |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
(If adding dates to the above immunization history section, put your initials by date(s) and sign here.) |
Title |
|
|
|
|
|
|
|
Date |
|
||||||||||||||||||||||||
|
Signature |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
(If adding dates to the above immunization history section, put your initials by date(s) and sign here.) |
Title |
|
|
|
|
|
|
|
Date |
|
||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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) |
MO |
DA |
YR |
MUMPS |
MO DA YR |
|
VARICELLA |
|
MO DA |
YR |
Physician’s Signature |
|
|
|
|
|
|
|||||||||||||||||
|
2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. |
|
|
|
|
||||||||||||||||||||||||||||||
|
Person signing below 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. |
||||||||||||||||||||||||||||||||||
|
Date of Disease |
|
|
|
|
Signature |
|
|
|
|
|
|
|
|
|
|
|
|
Title |
|
|
|
|
|
|
|
|
Date |
|
||||||
|
3. Laboratory confirmation (check one) |
|
Measles |
|
|
|
Mumps |
|
Rubella |
|
|
Hepatitis B |
|
|
Varicella |
|
|||||||||||||||||||
|
Lab Results |
|
|
|
|
|
Date |
MO |
DA |
YR |
|
|
|
(Attach copy of lab report, if available.) |
|
||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
VISION AND HEARING SCREENING DATA |
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Date |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Code: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P = Pass |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Age/Grade |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
F = Fail |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R |
L |
R |
L |
R |
L |
R |
|
L |
|
R |
|
L |
|
R |
L |
|
R |
L |
|
R |
L |
|
R |
L |
|
R |
|
L |
U = Unable to |
||||
|
|
|
|
|
|
|
|
|
|
|
test |
||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Vision |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R = Referred |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
G/C = Glasses/ |
|
Hearing |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Contacts |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Printed by Authority of the State of Illinois |
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(Complete Both Sides) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
Student’s Name
Last |
First |
Middle |
Birth Date
Month/Day/ Year
Sex School
Grade Level/ ID #
HEALTH HISTORY |
|
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER |
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
||||||
ALLERGIES (Food, drug, insect, other) |
|
|
|
MEDICATION (List all prescribed or taken on a regular basis.) |
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Diagnosis of asthma? |
|
|
Yes |
No |
Indicate Severity |
Loss of function of one of paired |
|
Yes |
No |
|
|
|
|
|
||
Child wakes during the night coughing? |
Yes |
No |
|
organs? (eye/ear/kidney/testicle) |
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Birth complications/prematurity? |
Yes |
No |
|
Hospitalizations? |
|
|
|
|
|
|
|
|
|
|||
|
When? What for? |
|
|
Yes |
No |
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
Developmental delay? |
|
|
Yes |
No |
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Blood disorders? Hemophilia, |
|
Yes |
No |
|
Surgery? (List all.) |
|
|
Yes |
No |
|
|
|
|
|
||
Sickle Cell, Other? Explain. |
|
|
When? What for? |
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
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 |
|
Yes |
No |
|
Family history of sudden death |
|
Yes |
No |
|
|
|
|
|
|||
exercise? |
|
|
|
before age 50? (Cause?) |
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
Eye/Vision problems? |
_____ |
Glasses |
Contacts |
Last exam by eye doctor _______ |
Dental |
9 Braces |
9 Bridge |
9 Plate |
Other |
|
|
|
|
|||
Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) |
Other concerns? |
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|||||||||
Ear/Hearing problems? |
|
|
Yes |
No |
|
Information may be shared with appropriate personnel for health and educational purposes. |
|
|||||||||
|
|
|
|
Parent/Guardian |
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Bone/Joint problem/injury/scoliosis? |
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
Signature |
|
|
|
|
|
|
Date |
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|||||
Entire section below to be completed by MD/DO/APN/PA |
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
||||||
PHYSICAL EXAMINATION REQUIREMENTS |
HEAD CIRCUMFERENCE |
|
HEIGHT |
WEIGHT |
|
|
|
BMI |
|
B/P |
||||||
|
|
|
|
|
|
|||||||||||
DIABETES SCREENING (Not required for daycare.) 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 QUESTIONAIRRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten.
Questionairre Administered? |
Yes |
No |
Blood Test Indicated? |
Yes |
No |
|
|
Blood Test Date |
Blood Test Result |
|
. |
|
||||||||||||||||
(If child resides in Chicago, blood test is required.) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
TB SKIN TEST Recommended only for children in |
|
|||||||||||||||||||||||||||
prevalence countries, or those exposed to adults in |
No Test Needed |
|
Test performed |
Date Read |
/ |
|
/ |
Result |
mm |
|||||||||||||||||||
LAB TESTS (Recommended) |
|
|
|
Date |
|
|
Results |
|
|
|
|
|
|
|
|
|
|
Date |
|
|
|
Results |
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
Hemoglobin or Hematocrit |
|
|
|
|
|
|
|
|
|
|
|
Sickle Cell |
(when indicated) |
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
Urinalysis |
|
|
|
|
|
|
|
|
|
|
|
|
|
Developmental Screening |
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
SYSTEM REVIEW |
Normal |
|
|
|
|
|
|
|
|
|
|
Normal |
|
|
|
|
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Skin |
|
|
|
|
|
|
|
|
|
|
|
|
|
Endocrine |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Ears |
|
|
|
|
|
|
|
|
|
|
|
|
|
Gastrointestinal |
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
Eyes |
Normal |
Yes |
No |
Objective screening Yes No |
Result______________ |
|
|
|
|
|
|
|
|
|
|
LMP |
|
|
||||||||||
|
Amblyopia |
Yes |
No |
Referred to Opthalmologist/Optometrist Yes |
No |
|
|
|
Neurological |
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
Nose |
|
|
|
|
|
|
|
|
|
|
|
|
|
Musculoskeletal |
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
Throat |
|
|
|
|
|
|
|
|
|
|
|
|
|
Spinal examination |
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
Mouth/Dental |
|
|
|
|
|
|
|
|
|
|
|
|
Nutritional status |
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Cardiovascular/HTN |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Mental Health |
|
|
|
|
|
|
|
|
|
|
|
|
||
Respiratory |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||
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 (for one year) |
Yes |
|
|
No |
Limited |
|
|||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||
Physician/Advanced Practice Nurse/Physician Assistant performing examination |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||
Print Name |
|
|
|
|
|
|
|
Signature |
|
|
|
|
|
|
|
|
|
|
|
|
|
Date |
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
Address |
|
|
|
|
|
|
|
|
|
|
|
Phone |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(Complete both sides)