Get Illinois Child Health Examination Form

The Illinois Child Health Examination Form serves as a vital document for ensuring the health and well-being of children enrolled in licensed child care facilities. This form gathers essential information regarding a child's immunization history, health screenings, and overall medical background, which is crucial for their participation in school activities. Parents and guardians are encouraged to complete this form accurately to support their child's health needs.

To ensure your child's health is properly documented, please fill out the form by clicking the button below.

Modify Form

The Illinois Child Health Examination form plays a crucial role in ensuring the well-being of children enrolled in licensed child care facilities across the state. This comprehensive document collects essential information about a child's health, including personal details such as the child's name, birth date, and school information, which are vital for tracking health status over time. One of the most significant sections of the form is dedicated to immunizations, where health care providers must document each vaccine administered, noting the dates and any medical contraindications. Additionally, the form requires a thorough health history to be completed by a parent or guardian, addressing allergies, medications, and any past medical conditions that could affect the child's health. Vision and hearing screenings, conducted by certified technicians, are also included to ensure that children are developing appropriately. Furthermore, the physical examination section must be completed by a licensed medical professional, detailing growth metrics such as height and weight, as well as any necessary screenings for conditions like diabetes or lead exposure. This form not only serves as a record of a child's health but also facilitates communication between parents, health care providers, and educational institutions, promoting a collaborative approach to child health management.

Document Breakdown

Fact Name	Detail
Purpose	The Illinois Child Health Examination form is required for children attending licensed child care facilities to ensure their health and readiness for school.
Governing Law	This form is governed by the Illinois School Code (105 ILCS 5/27-8.1), which mandates health examinations for school children.
Immunization Records	Health care providers must complete the immunization section, documenting each vaccine's date of administration.
Alternative Proof of Immunity	Parents can provide alternative documentation for immunity, such as clinical diagnosis or laboratory confirmation, if necessary.
Health History	Parents or guardians must complete a health history section, detailing allergies, medications, and any significant health issues.
Vision and Hearing Screening	Screening for vision and hearing must be performed by a certified technician, with results included in the form.
Physical Examination Requirements	A licensed health care provider must complete the physical examination section, including height, weight, and other health metrics.
Emergency Action Plan	Parents must indicate if any emergency action is needed at school due to their child's health condition, ensuring proper care is available.

Common PDF Forms

Workers Comp Illinois - Employers should list the part of the body affected by the injury.

Illinois Ui 28 - Employers should be familiar with audit procedures related to their refund claims.

The Free And Invoice PDF form is a document designed to facilitate billing and payment processes between businesses and clients. It helps in clearly outlining goods or services provided, along with their respective costs. Using this form can streamline transactions and ensure transparency in financial exchanges, and for those looking for one such resource, you can find it at documentonline.org/blank-free-and-invoice-pdf/.

Illinois Income Verification - The form includes sections for both client and employer to provide relevant details.

Misconceptions

Here are six common misconceptions about the Illinois Child Health Examination form:

Only children in daycare need this form. Many parents believe that this form is only required for children enrolled in daycare facilities. However, it is also necessary for children entering school, participating in sports, or attending certain camps.
Immunizations can be recorded by anyone. Some think that any adult can fill out the immunization section. In reality, a qualified health care provider must complete this part to ensure accuracy and compliance with health regulations.
All sections must be filled out for every child. While it's important to provide as much information as possible, not every section is mandatory for every child. Parents should focus on relevant health history and immunization details specific to their child.
Parents can skip the health history section. Some parents may feel that the health history section is optional. This is not true; it is essential for identifying any potential health issues that may affect the child's education or care.
Only a doctor can sign the form. Many believe that only a physician's signature is valid. However, signatures from other qualified health care providers, such as nurse practitioners or physician assistants, are also acceptable.
The form is only for physical health issues. It is a common misconception that the form only addresses physical health. In fact, it also includes sections for mental health and developmental concerns, which are equally important for a child's overall well-being.

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)

Dos and Don'ts

When filling out the Illinois Child Health Examination form, there are important guidelines to follow. Here are four things you should and shouldn't do:

Do ensure all sections are completed accurately, including personal information and immunization history.
Do attach any required documentation, such as a written statement for medically contraindicated vaccines.
Don't leave any fields blank. If a question does not apply, indicate that with "N/A" or a similar notation.
Don't forget to have the health care provider sign the form to verify the information provided.

Illinois Child Health Examination: Usage Instruction

Filling out the Illinois Child Health Examination form is an important step in ensuring your child's health and readiness for school. This process involves providing detailed information about your child's medical history, immunizations, and any health concerns. Follow these steps carefully to complete the form accurately.

Gather necessary information: Collect your child's personal details, including their name, birth date, sex, race/ethnicity, school, and grade level.
Provide contact information: Fill in your address and telephone numbers for both home and work.
Complete the immunization section: Ensure a health care provider fills out this part. They must note the date for each vaccine administered. If any vaccines are medically contraindicated, attach a written statement.
Fill out the health history: Answer all questions about allergies, medications, and any past medical issues. Be honest and thorough.
Have a health care provider conduct a physical examination: This section must be completed and signed by a qualified medical professional. They will assess your child's height, weight, and overall health.
Review and sign: Ensure that both you and the health care provider sign the form where indicated. This confirms that the information provided is accurate and complete.
Submit the form: Once completed, submit the form to your child’s school or child care facility as required.