Illinois Child Health Examination Form PDF Details

Are you taking your child in for a medical checkup or physical examination in the state of Illinois? If so, chances are you may have to fill out an Illinois School Physical Examination form. This health assessment is used by many child care providers and examiners throughout the state and provides valuable insights into identifying any potential risks that could become problems later on down the road for your little one. In this blog post, we'll guide you through all the sections of an Illinois School physical examination form, from what information it gathers to how best to fill it out. Read on to learn more about this important document and its role in keeping children healthy!

QuestionAnswer
Form NameIllinois Child Health Examination Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescertificate of child health examination, state of illinois certificate of child health examination 2021, illinois physical exam form, illinois physical exam

Form Preview Example

State of Illinois

Certificate of Child Health Examination

FOR USE IN DCFS LICENSED CHILD CARE FACILITIES

CFS 600

REV 2/2013

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. 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.

Vaccine / Dose

1

 

2

 

3

 

4

 

5

 

6

 

MO DA YR

MO DA YR

MO DA YR

MO DA YR

MO DA YR

MO DA YR

 

 

DTP or DTaP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tdap; Td or Pediatric

TdapTdDT

TdapTdDT

TdapTdDT

TdapTdDT

TdapTdDT

TdapTdDT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DT (Check specific type)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Polio (Check specific

IPV OPV

IPV OPV

IPV OPV

IPV OPV

IPV OPV

IPV OPV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

type)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hib Haemophilus

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

influenza type b

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B (HB)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella

 

 

 

 

 

 

 

 

COMMENTS:

 

 

 

 

 

 

 

(Chickenpox)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR Combined

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles Mumps. Rubella

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single Antigen

Measles

Rubella

Mumps

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vaccines

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal

Conjugate

Other/Specify

Meningococcal,

Hepatitis A, HPV,

Influenza

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 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 result)

VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN

Date

Age/

Grade

R

L

R

L

R

L

R

L

R

L

R

L

R

L

R

L

R

L

Vision

Hearing

Code:

P = Pass

F = Fail

U = Unable to test R = Referred G/C = Glasses/Contacts

IL444-4737 (R-02-13)

(COMPLETE BOTH SIDES)

Printed by Authority of the State of Illinois

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

 

 

Loss of function of one of paired

 

Yes

No

 

 

Child wakes during night coughing?

Yes

No

 

 

organs? (eye/ear/kidney/testicle)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth defects?

 

Yes

No

 

 

Hospitalizations?

 

Yes

No

 

 

 

 

 

 

 

 

When? What for?

 

 

 

 

 

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

Braces Bridge

Plate

Other

 

Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)

 

 

 

 

 

 

 

Ear/Hearing problems?

 

Yes

No

 

 

Information may be shared with appropriate personnel for health and educational purposes.

 

 

 

 

 

 

 

Parent/Guardian

 

 

 

 

 

Bone/Joint problem/injury/scoliosis?

Yes

No

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL EXAMINATION REQUIREMENTS

Entire section below to be completed by MD/DO/APN/PA

 

 

 

HEAD CIRCUMFERENCE if < 2-3 years old

 

 

HEIGHT

WEIGHT

 

BMI

 

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 YesNo Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) YesNo 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.

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

 

 

 

 

 

 

 

Gastrointestinal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eyes

 

 

 

 

 

Amblyopia

YesNo

Genito-Urinary

 

 

 

LMP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nose

 

 

 

 

 

 

 

Neurological

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Throat

 

 

 

 

 

 

 

Musculoskeletal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mouth/Dental

 

 

 

 

 

 

 

Spinal Exam

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardiovascular/HTN

 

 

 

 

 

 

Nutritional status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Respiratory

 

 

 

 

 

Diagnosis of Asthma

Mental Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently Prescribed Asthma Medication:

 

 

 

 

 

 

 

 

 

Quick-relief

medication (e.g. Short Acting Beta Agonist)

 

Other

 

 

 

 

 

Controller medication (e.g. inhaled corticosteroid)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 Limited

Print Name

(MD,DO, APN, PA)

Signature

 

Date

Address

 

 

Phone

 

 

 

 

 

 

 

(Complete Both Sides)