Illinois School Physical Form 2013-2026

FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013 State of Illinois Certificate of Child Health Examination Student s Name Birth Date Last First Address Middle Street City Sex Race/Ethnicity School /Grade Level/ID Month/Day/Year Parent/Guardian Zip Code 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* MO DA YR Tdap Td DT IPV OPV Vaccine / Dose DTP or DTaP Tdap Td or Pediatric DT Check specific type Polio Check specific type Hib Haemophilus influenza type b Hepatitis B HB COMMENTS Varicella Chickenpox MMR Combined Measles Mumps. Rubella Measles Single Antigen Vaccines Rubella Mumps 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 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 3. Laboratory confirmation check one Measles Lab Results MO DA Attach copy of lab result YR VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN Code Age/ Grade R L Vision Hearing IL444-4737 R-02-13 COMPLETE BOTH SIDES P Pass F Fail U Unable to test R Referred G/C Glasses/Contacts Printed by Authority of the State of Illinois HEALTH HISTORY ALLERGIES School Grade Level/ ID TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER MEDICATION List all prescribed or taken on a regular basis. Food drug insect other Diagnosis of asthma Child wakes during night coughing Yes No Loss of function of one of paired organs eye/ear/kidney/testicle Birth defects Hospitalizations When What for Developmental delay Blood disorders Hemophilia Sickle Cell Other Explain* Diabetes Surgery List all* Serious injury or illness Head injury/Concussion/Passed out TB skin test positive past/present Seizures What are they like TB disease past or present No If yes refer to local health department. Heart problem/Shortness of breath Tobacco use type frequency Heart murmur/High blood pressure Alcohol/Drug use Family history of sudden death before age 50 Cause Dizziness or chest pain with exercise Eye/Vision problems Glasses Contacts Last exam by eye doctor Other concerns crossed eye drooping lids squinting difficulty reading Ear/Hearing problems Bone/Joint problem/injury/scoliosis Bridge Plate Other Information may be shared with appropriate personnel for health and educational purposes.