Looking for a Il Dhs Forms And Templates? Download it for free!

Sex

School

Grade Level/ ID #

Birth Date

Student’s Name

Last

First

Middle

Month/Day/ Year

HEALTH HISTORY

TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER

ALLERGIES

MEDICATION (

(Food, drug, insect, other)

List all prescribed or taken on a regular basis.)

Yes

Loss of function of one of paired

Yes

Diagnosis of asthma?

Yes

organs? (eye/ear/kidney/testicle)

Child wakes during the night

hi ?

Yes

Hospitalizations?

Yes

Birth defects?

When? What for?

Developmental delay?

Yes

Blood disorders? Hemophilia,

Yes

Surgery? (List all.)

Yes

When? What for?

Sickle Cell, Other? Explain.

Diabetes?

Yes

Serious injury or illness?

Yes

Head injury/Concussion/Passed out?

Yes

TB skin test positive (past/present)?

Yes*

No *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

Alcohol/Drug use?

Yes

Heart murmur/High blood pressure?

Yes

Family history of sudden death

Yes

Dizziness or chest pain with

before age 50? (Cause?)

exercise?

Eye/Vision problems? _____

Last exam by eye doctor ______

Dental

Braces

Bridge

Plate Other

Glasses

Contacts

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

HEIGHT

WEIGHT

BMI

B/P

DIABETES SCREENING

BMI>85% age/sex Yes

And any two of the following: Family History Yes

(NOT REQUIRED FOR DAY CARE)

Ethnic Minority Yes

Signs of Insulin Resistance

Yes

At Risk Yes

(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.

Questionnaire Administered ? Yes

Blood Test Indicated? Yes

Blood Test Date

(Blood test required if resides in Chicago.)

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

No test needed

Test performed

high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines.

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

Skin

Endocrine

Ears

Gastrointestinal

LMP

Eyes

Amblyopia Yes

Genito-Urinary

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 Antagonist )

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

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

Modified

Yes

Limited

PHYSICAL EDUCATION

INTERSCHOLASTIC SPORTS (for one year)

Print Name

(MD,DO, APN, PA)