Fill a Valid Illinois Child Health Examination Form

The Illinois Child Health Examination form is a crucial document required for children attending licensed child care facilities in the state of Illinois. This form collects essential health information, including immunization records and health history, to ensure the well-being of children in educational settings. Parents and guardians must fill out this form accurately to facilitate their child's health assessments and compliance with state regulations.

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Open Illinois Child Health Examination Editor

Open Illinois Child Health Examination Editor

Table of Contents

The Illinois Child Health Examination form plays a crucial role in ensuring that children receive the necessary health assessments required for their education and well-being. This form is specifically designed for use in licensed child care facilities and schools across Illinois. It collects essential information about a child's health history, including immunizations, allergies, and any chronic conditions. Parents or guardians are required to fill out sections detailing allergies, medications, and previous health issues, while health care providers must verify this information through a physical examination. The form also includes a section for documenting vision and hearing screenings, which are vital for identifying any potential issues that could affect a child's learning. Additionally, the form outlines specific immunization requirements, ensuring that children are protected against various preventable diseases. By gathering comprehensive health information, the Illinois Child Health Examination form helps schools and child care facilities create a safe and supportive environment for every child.

Example - Illinois Child Health Examination Form

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

MO DA YR

DTP or DTaP

Tdap; Td or Pediatric

TdapTdDT

DT (Check specific type)

Polio (Check specific

 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

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

Loss of function of one of paired

Yes

Child wakes during night coughing?

Yes

organs? (eye/ear/kidney/testicle)

Birth defects?

Yes

Hospitalizations?

Yes

When? What for?

Developmental delay?

Yes

Blood disorders? Hemophilia,

Yes

Surgery? (List all.)

Yes

Sickle Cell, Other? Explain.

When? What for?

Diabetes?

Yes

Serious injury or illness?

Yes

Head injury/Concussion/Passed out?

Yes

TB skin test positive (past/present)?

Yes*

*If yes, refer to local health

department.

Seizures? What are they like?

Yes

TB disease (past or present)?

Yes*

Heart problem/Shortness of breath?

Yes

Tobacco use (type, frequency)?

Yes

Heart murmur/High blood pressure?

Yes

Alcohol/Drug use?

Yes

Dizziness or chest pain with

Yes

Family history of sudden death

Yes

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

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

Parent/Guardian

Bone/Joint problem/injury/scoliosis?

Yes

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 Yes No  Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No  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

Yes No

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
Address

(Complete Both Sides)

▼ PDF

Document Breakdown

Fact Name	Description
Purpose	The Illinois Child Health Examination form is used to ensure that children in licensed child care facilities meet health and immunization requirements.
Governing Law	This form is governed by the Illinois Child Care Act and regulations set forth by the Illinois Department of Children and Family Services (DCFS).
Immunization Records	Health care providers must complete the immunization section, documenting each vaccine administered along with the date.
Alternative Proof of Immunity	Parents can provide alternative proof of immunity through clinical diagnosis or laboratory confirmation for certain diseases.
Health History	A comprehensive health history must be completed by the parent or guardian, covering allergies, medications, and past medical issues.
Physical Examination	A licensed health care provider must conduct a physical examination, including height, weight, and other vital health metrics.
Emergency Action Plan	If a child has a health condition that requires special attention, an emergency action plan must be outlined on the form.

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