Free Illinois Child Health Examination Template

Detailed Guide for Filling Out Illinois Child Health Examination

Completing the Illinois Child Health Examination form is an essential step in ensuring your child's readiness for school and their overall health management. The form is comprehensive and requires detailed information about your child’s health history, immunizations, and the results of a physical examination. Here’s how to accurately complete the form:

1. Start with the Student’s Information section at the top of the form. Fill in the student's name, date of birth, sex, race/ethnicity, school details including grade level, and the student's ID number if applicable. Don’t forget the address where the student resides and the contact information for the parent or guardian.
2. Move to the Immunizations section. This part must be filled out by a health care provider. They will note the month, day, and year for each vaccine dose administered. Remember, if a vaccine is medically contraindicated, a separate written statement needs to be attached explaining why.
3. The Alternative Proof of Immunity section applies if the standard vaccination documentation is not available. This can include a clinical diagnosis or history of certain diseases verified by a physician, or laboratory confirmation of immunity. Again, a health care provider must complete this section.
4. In the Vision and Hearing Screening section, an IDPH certified screening technician must record the date of the screening and the results for both ears and eyes, indicating whether the student passed or failed, couldn’t be tested, or was referred for further examination.
5. Health History needs to be filled out and signed by a parent or guardian. This section asks for comprehensive health information, including allergies, medication, surgeries, hospitalizations, and any diagnosed conditions.
6. The Physical Examination Requirements section is for the examining health care provider to complete. They will fill in measurements, results from the diabetes screening (if applicable), and conduct a systemic review covering various health aspects from skin condition to mental health.
7. Don’t overlook the Lead Risk Questionnaire, necessary for children in certain age groups or living situations, and the TB Skin or Blood Test section, recommended for children in high-risk groups.
8. Finally, review the Lab Tests section. While recommended, these tests are not a mandatory part of the examination but provide valuable information about the child’s hemoglobin or hematocrit levels, and urine analysis among others.
9. The concluding sections of the form allow the health care provider to indicate any special needs or modifications that might be required in the school setting, and to approve participation in physical education and interscholastic sports.

Once all relevant sections of the form are completed, ensure that both the parent/guardian and the health care provider sign and date the form where indicated. This document then serves as a crucial record of your child’s health status and is typically required for school enrollment, ensuring that all necessary health information is communicated and any special needs are addressed.

FAQ Section: Illinois Child Health Examination Form

1. What is the Illinois Child Health Examination form?

   The Illinois Child Health Examination form is a document used to certify a child’s health status, including vaccination records, physical exams, and any medical history, for enrollment in DCFS licensed child care facilities, as well as public and private schools in Illinois.

2. Who needs to complete the Illinois Child Health Examination form?

   The form must be completed for children entering childcare, preschool, kindergarten, or any child new to the Illinois school system. Both a healthcare provider and the parent or guardian of the child are required to fill out portions of the form.

3. What vaccinations are recorded on the form?

   Vaccinations for DTP/DTaP, Tdap/Td, Polio, Hib (Haemophilus influenza type b), Hepatitis B, Varicella (Chickenpox), MMR (Measles, Mumps, Rubella), and other specified vaccines such as Pneumococcal Conjugate, Meningococcal, Hepatitis A, HPV, and Influenza are recorded on this form.

4. Is a vision and hearing screening mandatory?

   Yes, vision and hearing screenings are mandatory and must be performed by an IDPH certified screening technician. The results are documented on the form indicating whether the child has passed or failed these screenings.

5. How is alternative proof of immunity handled?

   Alternative proof of immunity can be provided through clinical diagnosis by a physician, a history of varicella disease verified by a health care provider, or laboratory confirmation of measles, mumps, rubella, hepatitis B, or varicella. Appropriate documentation must be attached to the form.

6. What if a vaccine is medically contraindicated for my child?

   If a specific vaccine is medically contraindicated for your child, a separate written statement must be attached to the form, explaining the medical reason for the contraindication.

7. Are there exceptions to the lead risk questionnaire and TB skin or blood test requirements?

   The lead risk questionnaire is required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school, and/or kindergarten, with a blood test being necessary if the child resides in Chicago or a high-risk zip code. The TB skin or blood test is recommended only for children in high-risk groups. Exceptions apply based on individual health conditions and geographic location.

8. How often does the Illinois Child Health Examination form need to be updated?

   The form needs to be completed upon initial enrollment into a childcare or school program in Illinois and may need to be updated based on the requirements of the specific school or daycare, or when significant changes to the child's health occur.

Filling out the Illinois Child Health Examination form can be daunting, and it's easy to make mistakes if you're not careful. Here is an expanded list of common errors to avoid:

1. Skipping the student's full name, including the last, first, and middle name, can lead to confusion, especially in schools with students who have similar names.

2. Entering the wrong date of birth, which is crucial for proper record-keeping and ensuring the child receives age-appropriate care.

3. Forgetting to check the sex, race, and ethnicity boxes, which are important for demographic records and can impact the understanding of health disparities.

4. Leaving the school grade level or ID number blank can create issues with tracking the child's health records within the school system.

5. Omitting parent or guardian contact information, making it difficult to reach out in case of emergencies or for follow-up information.

6. Incorrectly filling out the immunization dates or failing to note if a vaccine was medically contraindicated, which can affect the child's school enrollment status and health safety.

7. Neglecting to provide details on any alternative proof of immunity, such as a history of chickenpox or lab results, which are necessary for children without standard immunization records.

8. Overlooking the vision and hearing screening section, which are critical for detecting issues that could affect a child's learning and development.

9. Not completing the health history, including allergies and medications, can lead to oversight in the care and precautions needed for the child.

10. Forgetting to sign the form, by both the parent/guardian and the health care provider, renders the document unofficial and could delay processing.

Besides these points, it's equally important to review every section carefully:

• Ensure that the physical examination details, including measurements like height, weight, and BMI, are accurately recorded.

• Check if the lead risk questionnaire has been filled out for children in the required age group and setting.

• Confirm whether additional lab tests, if recommended, have been noted along with their results.

• Review the system review section to guarantee that any potential health issues are flagged for follow-up or intervention.

• Double-check that all sections requiring a checkmark, signature, or date have been duly filled in to ensure the form is considered valid and complete.

The State of Illinois Certificate of Child Health Examination is a critical document for ensuring that children entering school or daycare facilities in Illinois have met the health requirements necessary for attendance. This form is just one component of a comprehensive approach to child health and safety. There are several other important forms and documents that often accompany this examination form to provide a full picture of a child's health and medical history. These documents ensure that health care providers, parents, and educational institutions can collaborate effectively to support the health and well-being of children.

1. Immunization Record: This document provides a complete history of the child's vaccinations, ensuring that all immunizations meet the state's requirements for school entry.
2. Dental Examination Form: Details the child's oral health status, identifying any issues that may require attention and confirming that a dental check-up has been conducted as per state health requirements.
3. Vision Examination Report: Contains information on the child's visual acuity, screening for conditions like amblyopia and strabismus, and noting if corrective lenses are needed.
4. Proof of Lead Screening: Required for children of certain ages or in specific areas, this document verifies that the child has been screened for lead poisoning, which can significantly impact health and development.
5. Sports Physical Examination Form: For children participating in interscholastic sports, this form assesses the child's physical ability to safely engage in sports activities.
6. Medication Authorization Form: If a child needs to take medication during school hours, this form provides authorization and instructions for school staff on how to administer these medications.
7. Emergency Contact and Medical Information Form: Lists contact information for parents and guardians and provides critical medical information in case of an emergency.
8. Allergy Action Plan: For children with allergies, this plan details the allergens, symptoms of an allergic reaction, and steps to take if the child is exposed to an allergen.
9. Asthma Action Plan: Similar to the Allergy Action Plan, but for children with asthma, detailing how to manage the child's condition, recognize signs of an asthma attack, and emergency procedures.
10. Sickle Cell Screening Form: Particularly for areas or populations at high risk, this form indicates whether the child has been screened for sickle cell disease or trait.

Together, these forms create a comprehensive health profile for children, facilitating the provision of care and support tailored to each child's needs. It is vital for parents, guardians, and caregivers to provide complete and accurate information on all required forms. This collaboration between families and health care providers ensures not only the safety and wellbeing of children but also supports a healthy learning environment within schools and childcare facilities.

• The Vaccine Exemption Form shares similarities with the Illinois Child Health Examination form because both documents can require written statements to explain medical reasons for not following typical vaccination or health requirements. The Vaccine Exemption Form is specifically for vaccine exemptions, whereas the Illinois form includes this as part of a broader health examination.

• School Sports Physical Form is similar because it also assesses a child's health to ensure safe participation in physical activities. Both forms include sections on physical examinations and may require information on heart health, asthma, and physical fitness, catering to the child's well-being in physically demanding environments.

• The Pre-Admission Health History Form used by many schools and child care facilities. Like the Illinois form, it collects detailed health history, including allergies, medications, and past illnesses, ensuring the institution can provide a safe and accommodating environment for the child.

• Immunization Record Form closely relates by detailing a child’s vaccination history against common diseases. The Illinois Child Health Examination form integrates immunization records, marking each vaccine's dates, similar to what the Immunization Record Form focuses on exclusively.

• A Lead Screening Consent Form is akin to the Illinois form's section that addresses lead risk and mandates blood tests for children in certain areas or circumstances. Both ensure early detection and prevention of lead exposure in children.

• The Vision and Hearing Screening Permission Form parallels the Illinois form through its concern for a child's sensory health, mandating assessments that identify potential vision and hearing issues early on.

• Emergency Medical Authorization Form resembles the section of the Illinois form that calls for information on allergies and chronic conditions like asthma or diabetes, preparing schools to respond effectively to health emergencies.

• A Medication Administration Form for schools or childcare centers is related by gathering detailed information on a child's medication needs, ensuring they receive proper medication during school hours—much like the Illinois form's section on regular medications.

When filling out the Illinois Child Health Examination form, attention to detail is paramount. Ensure the health and safety of the child by following these guidelines:

• Use black or blue ink to ensure the form is legible and photocopies well.
• Verify all information for accuracy before submission, including double-checking the dates and doses of immunizations.
• Ensure the health care provider signs and dates the form, as it is a required step for validation.
• If applicable, attach a separate written statement for any specific vaccine that is medically contraindicated, clearly explaining the medical reason.
• Fill out every section completely; do not leave blank spaces if the information is available or applicable.
• Ensure that any history of diseases like varicella (chickenpox) is verified either by a physician, school health professional, or health official as indicated on the form.
• Include a current contact number for immediate access in case additional information or clarification is required.
• Keep a photocopy of the completed form for your records before submitting it to the required authority.

• Don't use pencil or colors other than black or blue ink as they may not be acceptable or legible.
• Avoid guessing immunization dates; confirm all dates with official immunization records.
• Don't leave sections incomplete; if a section doesn't apply, write "N/A" (Not Applicable) to indicate it was intentionally left blank.
• Avoid submitting the form without the necessary signatures from the health care provider, as unsigned forms will be considered invalid.
• Don't forget to attach additional medical statements for contraindications or alternative proofs of immunity when necessary.
• Refrain from waiting until the last minute to complete the form to avoid any delays in the child's enrollment or participation in school activities.
• Don't overlook the importance of the Vision and Hearing Screening section, which must be completed by an IDPH certified screening technician.
• Avoid sending the original copy without keeping a photocopy for your personal records.

The Illinois Child Health Examination form is an important document, but often, misconceptions arise about its requirements and significance. Let's address some of these common misunderstandings.

• All children need to complete the form only once. In reality, the form needs to be updated for certain grade levels or when children participate in sports, indicating a need for periodical updates throughout a child’s school career.
• Only a doctor can complete the form. While it's true that a healthcare provider must fill out most sections, parents or guardians are also responsible for providing comprehensive health history information on the form.
• The form is only for school records. Besides schools, the information might be necessary for sports teams, summer camps, and other extracurricular activities to ensure the safety and well-being of the child.
• Immunizations are the only focus of the form. Although a big part of the form is dedicated to confirming immunization status, it also covers general health history, physical examination results, and other important health information.
• There’s no need to mention over-the-counter medications. The form has a section for medications taken on a regular basis, which includes both prescription and over-the-counter medications, due to their potential relevance to the child’s health care.
• Asthma details are only necessary if the child uses a prescription inhaler. Any history of asthma, including symptoms and treatments, should be reported to provide a comprehensive understanding of the child’s condition, not just prescription medication use.
• Vision and hearing tests are optional. For a comprehensive health evaluation, vision and hearing screenings are crucial components and must be conducted by a certified screening technician.
• Personal health history details are irrelevant. The child’s personal health history, including allergies, medications, and past illnesses or surgeries, provides essential context for health care providers and educators to ensure proper care and accommodations are available.

Correcting these misconceptions ensures comprehensive health surveillance and support for children in compliance with Illinois state requirements, fostering a healthy and conducive learning environment.

Filling out the Illinois Child Health Examination form is a crucial step in ensuring the well-being of children, especially as they engage in various activities and educational settings. Here are five key takeaways to keep in mind when handling this essential document:

• Accuracy is essential: Be thorough and accurate when completing the form. Every section, from immunizations to health history, requires detailed information. This accuracy helps ensure children are safe and health risks are minimized in communal settings like schools and daycare facilities.
• Up-to-date immunization records: Immunizations are a significant part of the form. It's crucial to record the month, day, and year for each dose administered. If a vaccine is medically contraindicated, attaching a written statement from a healthcare provider explaining the reason is necessary. This documentation is vital for the child’s entry into child care or school, adhering to state health regulations.
• Comprehensive health history: The form includes sections for detailing the child’s health history, allergies, medications, and any diagnosed conditions, such as asthma. Completing this section thoroughly helps ensure that care providers fully understand the child's health background for optimal care and emergency preparedness.
• Vision and hearing screenings: Vision and hearing are tested and recorded by certified screening technicians. These screenings are essential for early detection of potential issues that could affect the child’s learning and social interactions. The outcomes, such as "Pass" or "Fail," guide further actions needed.
• Sharing information: By signing the form, parents or guardians agree that the information can be shared with appropriate personnel for health and educational purposes. This shared knowledge ensures that all caretakers, from teachers to school nurses, are aware of the child’s health needs and can act accordingly in daily activities or emergencies.

This form acts as a comprehensive health snapshot, assisting in safeguarding the well-being of children in care and educational settings. As such, ensuring its completeness and accuracy is a collective responsibility among parents, guardians, and healthcare providers.