Certificate of Child Health Examination - Illinois

State of Illinois
Certificate of Child Health Examination
IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) P r inted by Aut hority of the S ta te of I l linois
Student’s Na me
Last First Midd le
Birth Date
Month/Day/Year
Sex
Race/Ethnicity
School /Grade Level /ID#
Address Street City Zip Code
Parent/Guardian Telepho ne # 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
d eterm in e if the vaccine wa s giv en after the m inimum int erv al or ag e. If a specific vaccine is medically contraindicated, a separate written statement must be
attached explaining the me dical reason for the contrai ndic ation.
Vacc in e / Dos e
1
M O DA YR
2
M O DA YR
3
MO DA YR
4
M O DA YR
5
M O DA YR
6
MO DA YR
DTP or DTaP
Tdap; Td or P ediatric
DT (
Check specific type)
TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT
Polio (Check specifi c
type)
IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV
Hib Haemophilus
influenza type b
Hep at itis B (HB)
Varicella
(Chickenpox)
COMMENTS:
MMR Combined
Measles Mumps. Rubella
Single Antigen
Vaccines
Measles Rubella Mumps
Pneumococcal
Conjugate
Other/Specify
Meningococcal,
Hepa titis 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 h ere.)
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, 2 002, must be confir med by laborator y e vidence.)
*MEASLES (Rubeola)
MO DA YR
MUMPS
MO DA YR
VARICE LLA
MO DA YR
Phy sician’s Sig nature
2. History of vari cella (chickenpox) disease is acceptable if verified by health ca re provider, school health professio nal or health official.
Person signing be low is verifying that the parent/guardian’s descriptio n of varice lla d isease his to ry is indicative of past infect io n and is accepting suc h history as docu mentation of disease.
Date of Disease Signature Title Date
3. Laboratory confirmation (check one)
Measles Mumps Rubella Hepatiti s B Varicella
Lab Results Date MO DA YR (Atta ch copy of lab result)
VISIO N AND H EARING SCREENI NG BY IDPH CERTIFI ED SCREENI NG TECHNICIAN
Date
Code:
P = Pass
F = Fail
U = Unable to test
R = Referred
G/C =
Glasses/Contacts
Age/
Grade
R L R L R L R L R L R L R L R L R L
Vision
Hearing
FOR USE IN DCFS LICENSED CHILD CARE FAC ILITIES
CFS 600
Rev 2/2013
Page 1/2
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