Illinois Department Of Human Services Certificate Of Child Health Examination
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2I
D
P
H
LLINOIS
EPARTMENT OF
UBLIC
EALTH
I
D
H
S
LLINOIS
EPARTMENT OF
UMAN
ERVICES
C
C
H
E
ERTIFICATE OF
HILD
EALTH
XAMINATION
(Information on this form may be shared with appropriate personnel for health and educational purposes.)
Please Print
Student’s Name
Birth Date
Sex
Grade Level
ID#
Address
Street
City
ZIP
Parent/
Telephone#
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
MO
DA
YR
MO
DA
YR
MO
DA
YR
MO
DA
YR
MO
DA
YR
MO
DA
YR
VACCINE/DOSE
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)
Comments:
Varicella (Chickenpox)
Combined Measles, Mumps and Rubella (MMR)
Measles (Rubeola)
Rubella (3-day measles)
Mumps
Pneumonococcal (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, meningoccal, etc)
Health care provider (MD, APN, PA, school health professional, health official) verifying above immunization history must sign below.
Signature
Title
Date
Signature
Title
Date
(If adding dates to the above immunization history section, put your initials by date(s) and sign here.)
Signature
Title
Date
(If adding dates to the above immunization history section, put your initials by date(s) and sign here.)
A
P
I
LTERNATIVE
ROOF OF
MMUNITY
1. Clinical diagnosis is acceptable if verified by physician
*(All measles on or after July 1, 2002, must be confirmed by laboratory evidence.)
*M
(Rubeola)
MO
DA
YR
M
MO
DA
YR
V
MO
DA
YR
Physician’s Signature
EASLES
UMPS
ARICELLA
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)
V
H
S
D
ISION AND
EARING
CREENING
ATA
This section to be completed by IDPH certified screening personnel, if pre-existing approved IDPH for is not available.
Pre-school – annually beginning at age 3; School age – during school year at required grade levels.
Date
Code:
P=Pass
F=Fail
U=Unable to test
Age/Grade
R=Referred
G/C=Glasses/
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
Contacts
Vision
Hearing
Printed by Authority of the State of Illinois (over)
IL 444-4737 (N-11-02)
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