Health Requirements from the Illinois State Board of Education Health requirements for the students of Illinois are summarized below.

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1 Health Requirements from the Illinois State Board of Education Health requirements for the students of Illinois are summarized below. ALL Illinois State Board of Education health requirements must be completed by July 1, 2014 in order for your child to begin school in the fall. Grades referred to below are what is effective in the school year. Health Examination & Immunization: Students entering pre-kindergarten and sixth grade, and students newly transferring to Saint Clement in any grade, must submit proof of a health examination and immunization record. The exam form, signed by a doctor, must have taken place after August 31, The Health History section must be completed and signed by a parent. Eye Examination: Students entering kindergarten and students who have newly transferred from out of state to Saint Clement School in any grade must submit an eye exam form, signed by their eye doctor. The exam must have taken place after August 31, Dental Examination: Students entering kindergarten, second, and sixth grade must submit a dental exam form, signed by their dentist. The exam must have taken place after vember 15, 2013.

2 Please Print Student s Name STATE OF ILLINOIS DEPARTMENT OF HUMAN SERVICES CERTIFICATE OF CHILD HEALTH EXAMINATION Birth Date Sex School Grade Level /ID# Last First Middle Month/Day/ Year Parent/ Telephone # Address Street City ZIP code Guardian Home Work IMMUNIZATIONS: To be completed by health care provider. te 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 Diphtheria, Tetanus and Pertussis (DTP or DTaP) Diphtheria and Tetanus (Pediatric DT or Td) Inactivated Polio (IPV) Oral Polio (OPV) Haemophilus influenzae type b (Hib) Hepatitis B (HB) Varicella (Chickenpox) Combined Measles, Mumps and Rubella (MMR) Measles (Rubeola) Comments Rubella (3-day measles) Mumps Pneumococcal (not required for school entry)!pcv7!ppv23!pcv7!ppv23!pcv7!ppv23!pcv7!ppv23!pcv7!ppv23!pcv7!ppv23 Check specific type (PCV7, PPV23) Other (Specify hepatitis A, meningococcal, etc.) Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. Title Date (If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Title Date (If adding dates to the above immunization history section, put your initials by date(s) and sign here.) 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) MUMPS VARICELLA Physician s 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 Title Date 3. Laboratory confirmation (check one)! Measles! Mumps! Rubella! Hepatitis B! Varicella Lab Results Date (Attach copy of lab report, if available.) VISION AND HEARING SCREENING DATA Date Age/Grade Vision Hearing IL (R-01-05) Pre-school annually beginning at age 3; School age during school year at required grade levels R L R L R L R L R L R L R L R L R L R L Printed by Authority of the State of Illinois (Complete Both Sides) Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/ Contacts

3 Student s Name Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year 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? Child wakes during the night coughing Birth defects? Developmental delay? Blood disorders? Hemophilia, Sickle Cell, Other? Explain. Indicate Severity Loss of function of one of paired organs? (eye/ear/kidney/testicle) Hospitalizations? When? What for? Surgery? (List all.) When? What for? Diabetes? Serious injury or illness? Head injury/concussion/passed out? TB skin test positive (past/present)? * Seizures? What are they like? TB disease (past or present)? * Heart problem/shortness of breath? Tobacco use (type, frequency)? Heart murmur/high blood pressure? Alcohol/Drug use? Dizziness or chest pain with exercise? Eye/Vision problems? Glasses! Contacts! Last exam by eye doctor Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Family history of sudden death before age 50? (Cause?) Dental!Braces!Bridge!Plate Other Other concerns? *If yes, refer to local health department. Ear/Hearing problems? Bone/Joint problem/injury/scoliosis? Entire section below to be completed by MD/DO/APN/PA Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Date (*INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES) PHYSICAL EXAMINATION REQUIREMENTS HEIGHT WEIGHT BMI B/P DIABETES SCREENING BMI> 85% age/sex!! And any two of the following: Family History!! Ethnic Minority!! Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans)!! At Risk!! LEAD RISK QUESTIONNAI RE* 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 Indicated?!! Blood Test Date Blood Test Result (Blood test required in Chicago and other high risk zip codes.) TB SKIN TEST Recommended only for children in high -risk groups including children who are immunosuppressed due to HIV infection or other conditions, recent immigrants from high prevalence countries, or those exposed to adults in high -risk categories. See CDC guidelines. Date Read / / Result mm LAB TESTS *INDICATES TESTING MANDATED FOR STATE LICENSED CHILD CARE FACILITIES Hemoglobin * or Hematocrit * Date Results Date Results Sickle Cell * (as indicated) Urinalysis Other SYSTEM REVIEW rmal Comments/Follow-up/Needs rmal Comments/Follow-up/Needs Skin Ears Endocrine Gastrointestinal Eyes rmal!! Objective screening!! Result Genito-Urinary Amblyopia!! Referred to Opthalmologist/Optometrist!! Neurological LMP se Throat Mouth/Dental Cardiovascular/HTN Respiratory NEEDS/MODIFICATIONS required in the school setting Musculoskeletal Spinal examination Nutritional status Mental Health 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)?!! If yes, please describe. On the basis of the examination on this day, I approve this child s participation in (If or Modified,please attach explanation.) PHYSICAL EDUCATION!! Modified! INTERSCHOLASTIC SPORTS (for one year)!! Limited! Physician/Advanced Practice Nurse/Physician Assistant performing examination Print Name Date Address Phone (Complete both sides)

4 State of Illinois Eye Examination Report Illinois law requires that proof of an eye examination by an optometrist or physician who provides complete eye examinations be submitted to the school no later than October 15 th of the year the child is first enrolled or as required by the school for other children. The examination must be completed within one year prior to the child beginning school. Student Name: Birth Date: Sex: Grade: (Last) (First) (Middle Initial) (Mo.) (Day) (Yr.) Parent or Guardian: Phone: (Last) (First) (Area Code) Address: County: (Number) (Street) (City) (Zip Code) Case History To Be Completed By Examining Doctor Date of Exam: Ocular History: rmal or Positive for: Medical History: rmal or Positive for: Drug Allergies: NKDA or Allergic to: Other Information: Examination Refraction: Distance Near Right Left Both Both Unaided Visual Acuity: 20 / 20 / 20 / 20 / Best Corrected Visual Acuity: 20 / 20 / 20 / 20 / Was refraction performed with cycloplegic agents? rmal Abnormal t Able to Assess Comments External Exam (eye and adnexa) Internal Exam (media, lens, fundus, etc.) Neurological Integrity (pupils) Binocular Function (stereopsis) Accommodation and Vergence Color Vision IOP (glaucoma) Oculomotor Assessment Other: Diagnosis rmal Myopia Hyperopia Astigmatism Strabismus Amblyopia Other: Recommendations 1. Corrective Lenses:, glasses should be worn for: Constant Wear Near Vision Far Vision May Be Removed for Physical Education 2. Preferential seating recommended: Comments: 3. Recommend re-examination: 3 months 6 months 12 months Other Print Name: Optometrist or Physician Who Provides Eye Examinations Address: : Optometrist or Physician Who Provides Eye Examinations Consent of Parent or Guardian I agree to release the above information on my child or ward to appropriate school or health authorities. (Parent or Guardian s ) Phone:

5 To be completed by the parent (please print): Illinois Department of Public Health PROOF OF SCHOOL DENTAL EXAMINATION FORM Student s Name: Last First Middle Birth Date: / / Address: Street City ZIP Code Telephone: (Month/Day/Year) Name of School: Grade Level: Gender: Male Female Parent or Guardian: Address (of parent/guardian): To be completed by dentist: Oral Health Status (check all that apply) Dental Sealants Present Caries Experience / Restoration History A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1 st molars. Untreated Caries At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present. Soft Tissue Pathology Malocclusion Treatment Needs (check all that apply) Urgent Treatment abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling Restorative Care amalgams, composites, crowns, etc. Preventive Care sealants, fluoride treatment, prophylaxis Other periodontal, orthodontic Please note of Dentist Date Address Street City ZIP Code Telephone Illinois Department of Public Health, Division of Oral Health TTY (hearing impaired use only) Printed by Authority of the State of Illinois P.O.# M 10/05

Location Address Number Belvidere 2229 Anderson Dr. (847) x 1913

Location Address Number Belvidere 2229 Anderson Dr. (847) 991-2090 x 1913 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 STATE OF ILLINOIS DEPARTMENT OF HUMAN SERVICES CERTIFICATE OF CHILD HEALTH EXAMINATION