Child Health Examination Form Page 2
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1
2Sex
School
Grade Level/ ID
Birth Date
#
Last
Student’s Name
First
Middle
Month/Day/ Year
HEALTH HISTORY
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
ALLERGIES
Yes
List:
MEDICATION
Yes
List:
(Prescribed or
No
No
(Food, drug, insect, other)
taken on a regular basis.)
Diagnosis of asthma?
Yes
No
Loss of function of one of paired
Yes
No
Yes
No
organs? (eye/ear/kidney/testicle)
Child wakes during night coughing?
Birth defects?
Yes
No
Hospitalizations?
Yes
No
When? What for?
Developmental delay?
Yes
No
Blood disorders? Hemophilia,
Yes
No
Surgery? (List all.)
Yes
No
Sickle Cell, Other? Explain.
When? What for?
Diabetes?
Yes
No
Serious injury or illness?
Yes
No
Head injury/Concussion/Passed out?
Yes
No
TB skin test positive (past/present)?
Yes*
No *If yes, refer to local health
department.
Seizures? What are they like?
Yes
No
TB disease (past or present)?
Yes*
No
Heart problem/Shortness of breath?
Yes
No
Tobacco use (type, frequency)?
Yes
No
Heart murmur/High blood pressure?
Yes
No
Alcohol/Drug use?
Yes
No
Dizziness or chest pain with
Yes
No
Family history of sudden death
Yes
No
before age 50? (Cause?)
exercise?
Eye/Vision problems? _____
Last exam by eye doctor ______
Glasses Contacts
Dental
Braces
Bridge
Plate Other
Other concerns?
(crossed eye, drooping lids, squinting, difficulty reading)
Ear/Hearing problems?
Yes
No
Information may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
Bone/Joint problem/injury/scoliosis?
Yes
No
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
BMI85% age/sex Yes
No
And any two of the following: Family History Yes No
(NOT REQUIRED FOR DAY CARE)
Ethnic Minority Yes No Signs of Insulin Resistance
Yes No At Risk Yes No
(hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans)
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 (
Date
Results
Date
Results
Recommended)
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
Screening Result:
Eyes
Genito-Urinary
LMP
Screening Result:
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
DIETARY
required in the school setting
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.)
Yes
No
Modified
Yes
No
Modified
PHYSICAL EDUCATION
INTERSCHOLASTIC SPORTS
Print Name
Signature
Date
(MD,DO, APN, PA)
Address
Phone
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