FORUSTffO6FS cFs@ R€ vsffi CAREFACilT'ES CIFffi LGEI{SEOCHIU' 1D) S"arBoFlultrcrs BTFiRT$E$r orlluli:a} Ssxn rcEs CtRTIErcarc or C-rrn.n Eear.rg Exanmtarroru Shrdent's $traIne lrsr firsr lttiddre IMMuNuAnoNs: To be complettatva"ur*t@dce artminisrc.red- Th" &e vaccine rvas givan qfter the minisum iote*al or aga If a speei&c vacdae is medically co*trairdicated, a separate *ritten sart€ E€ at mu$ b; a6lch€ d erplaining Diphtluria and Tetanus {Pediatric DT orTd) Haemophilus influenrzae gpe b (Hib) C.onrbined Measles, Mumps aad RubeIaG.&rR) Othrs tspceiry b€ patitis .A* aeaisgo.oscat, eiE ) Ilealth € are pioyider {MD, DO, APN, PA sshool heal& prsf€ ssiapal, t ALTEEIqAflW PE@F' OF &{MINTITY l. Clittictl diagnosb is aoceptalle if,verified by phpiciar. {AIl r*i* oass aig"*"a o oruti"t jlrlEASLES @ubeola) mo $A Ya i|{IIMPS Mo DA yR Y-{RICELLA. Mo Dr yE Phrridna'sSiqr*are 2- Eistory of variclla (.hl$enpm) ilismsr fu acceptsble lf y€ ftfied by he*th carr proliner Date afDls:asc Siemtrrre Titla Ilcle 3. l,aberaiorg conftrration (ehee[, s!e] ,,ab&e$rl* trMssles llate B Mumps I'O I}A YP trRubella trEepatitisB [YariceUa fi.f*nr{r cnrrs of lch mrr* lf nsailohlp } VISION AI{D EE-ATING SCREEITTI}{C DATA Pre-sdrool-ranc*Ilybegiebgntsge3; sc&.oolage-durirgacLoolyear*irnrdmdgradelereh $st€ Codr: P-Pas F=Sail U=Un*blato te3t R=Referred C/C=elase, CorbEts &geErnde RL RL R L l( L R L RL R L R L R L RL f ision llBarlqg Prinfed ht Authorig oft}e State ofUliaois (Comdsre Both Sids) IIi:H-4737(e{l-o5)
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FORUSTffO6FScFs@R€vsffi
CAREFACilT'ES
CIFffiLGEI{SEOCHIU'
1D)S"arBoFlultrcrs
BTFiRT$E$r orlluli:a} Ssxn rcEsCtRTIErcarc or C-rrn.n Eear.rg Exanmtarroru
Shrdent's $traIne lrsr firsr lttiddre
IMMuNuAnoNs: To be complettatva"ur*t@dce artminisrc.red- Th"&e vaccine rvas givan qfter the minisum iote*al or aga If a speei&c vacdae is medically co*trairdicated, a separate *ritten sart€E€at mu$ b; a6lch€d erplaining
Diphtluria and Tetanus {Pediatric DT orTd)
Haemophilus influenrzae gpe b (Hib)
C.onrbined Measles, Mumps aad RubeIaG.&rR)
Othrs tspceiry b€patitis .A* aeaisgo.oscat, eiE )
Ilealth €are pioyider {MD, DO, APN, PA sshool heal& prsf€ssiapal, t
ALTEEIqAflW PE@F' OF &{MINTITYl. Clittictl diagnosb is aoceptalle if,verified by phpiciar. {AIl r*i* oass aig"*"a o oruti"t
jlrlEASLES @ubeola) mo $A Ya i|{IIMPS Mo DA yR Y-{RICELLA. Mo Dr yE Phrridna'sSiqr*are2- Eistory of variclla (.hl$enpm) ilismsr fu acceptsble lf y€ftfied by he*th carr proliner
Date afDls:asc Siemtrrre Titla Ilcle3. l,aberaiorg conftrration (ehee[, s!e]
,,ab&e$rl*
trMsslesllate
B Mumps
I'O I}A YP
trRubella trEepatitisB [YariceUafi.f*nr{r cnrrs of lch mrr* lf nsailohlp }
Diagnosis of as&ma?C&ild wakes duriq th6 night corrghhg?
Y€s NoYcc NoIdicate Serrerity Loss ot;Ulclion ofooc ofpaircd
orgaos? (eSdearlkidney/resticle) fcs No
Birlh complicatious/premtmit5{ Yes No lrospSatatoaglMeD? \tth*foft Yes NoDevelopaental delay? Ym No
Blood disorders? HemopliliqSic.lde CelL Other? Exrlain. Yes No Surgqll {Li*att}
$Ih*al? Whatfot'? fes NoDi*betes? Ys No Serious injury or itkrcss? fes NrHead i4iury/Coacussion/Passed out? Ycs No TB skin twtpositive tpost/prsen$? Ycs* No 'Ifyeq rsferto local heallh
dopartmentEeizurcs9 Whaf arethry likc? Ycs No TB diseass (past or prisc,ltp fes* NcI{eart problem/Shortress of breath? Yes No lbbacco use (tyIE, AoqueacryP i{es Nofieart rnurmurlHigh blood pressure? fes No AlcohollDrug use? lls NaDieziness or chesi painwithexercise? Yes No Faorily &istory of sudilqr &otf,
Ear/lleadng probleus? fes No emoalaE D. rBeEdsrhaptrsrtal6pm@slfqhBlthad drmiomtpurpcses-ParmtlcuaraltotrS88slre--,- IlsteBoae/Joint problediqiury/scoliosis?
Entire ssctltn bslsr to be sompleted by MIIIDO/API{/FAP$YSICALEXAMINAfi{}NREQEIIRE*IENTS I{EADCIRCUMFEREI.ICE EEIGg'T frErcET E]ilr !!lpDI-{BETES SCREENII'IG (Not required for daycare.) BMI>fs96 age/s* yesE NoB -Ard any rwo of ,* ronEtlmicMiamity YeE NoE $ignsoflxdinReslstarce{hypcr&asim,dyslipiderria.polycrrsticovariaasydrolne,:caathosis{qdceg) yesB NoE }.tnbt yesE NctlIEAI) RISI( QIJESfIOIiASry &.srrJjb, tnd*, ac" e3*r" taro