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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 }

VISION AI{D EE-ATING SCREEITTI}{C DATAPre-sdrool-ranc*Ilybegiebgntsge3; sc&.oolage-durirgacLoolyear*irnrdmdgradelereh

$st€ Codr:P-PasF=SailU=Un*blato

te3tR=ReferredC/C=elase,CorbEts

&geErndeRL RL R L l( L R L RL R L R L R L RL

f ision

llBarlqgPrinfed ht Authorig oft}e State ofUliaois

(Comdsre Both Sids)IIi:H-4737(e{l-o5)

$frdert's Name'-L!st. Firs Mirb

Bir&DateM6hlkdvan

Ssr idrosl SrtldeIiveUID#

]ILLEI(GIIJ$ (Fo0d,dnrg: iesecL oecr) UUipICATION o.nn anFsiHof ukcaerrenlrbgieJ

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,

before *ge 5O? {Carrse?} Ycs NoEye/Visicxrproblems? __- Glasses tr Co*""@Odrer concerns? (crossed eyq &oopirg liib, quinting rlifficulty rcadag)

D€dal 9&aces 9Bridgo 9pl*e O&rO&erconcems?

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

Quesfanairrea&rdnisterred? Yestl Notr BloodTestlndlcateat?- yestr ]vtotr gtood1.i;D*; -- BlsodTc$fesult -

TB SNIFI TSST Rcoqryndd onlJr f"" .UA.J;a ligb;k;*rl6 t*trenalance courtries. * e* * ll[gedd E Test perfonned Date Baxr / I RsIt I rflrLAB TESTS @ecornrnmded) I Dare Results Dare R*ults

H*moglobin or llesrsatrit lickle CelI (w*:ea iadi:ated)Urinalysis )evelopm;ntal Scr€edngSYSTEMBE1rIEW tloraal Comments/Fcllow-gNeads NonaaI CommmB/Follow-uplNee&Ski{r EadoqrineEars CastroinHialEyes lionnal YesE NoCt Objectivcscreaiq fc€ lta[I Rcsuh

Amblyopia Yestr NoE Rafcrredtooprhalmolqisropioeerrisr y;tr-m--Genito-IJrina'y LMPNeurological

Nr:ge Mussrloskolaalthroat Spiral examiaaioafuIouth,IDental Nulritiooal sEnrsCardiovamular/IlTN

Ment l EIerIthRespiratoryN$EDSIiII0IIIFICATIOIYS required in &r schoot sening DIETARY Nec&lResricions

SPECf,4L INSTAUCrTONS/I}EyICES e.9 safety gtasscs, gless re" che$ pro*cror fw arb'tkrr4 Faccmakcr, pro$haic drvicc" doral kidge, frlsc tecth a&letic srppsrrxirp

MENTAL rtEALrgno:rHER is6eremyrling else&eschoolshorddf,:nd, abornrhissrrd"ar?

!{1911vodd lile to dscpss thb gnrdent'shes$h with schoot or scbool hcahh persooa:! chccii rirle: E r*ursc Il reacU E ccraselor tr nimipar

Yes Il !!q l1 fy€s.ptoasedscribaC)n the bcds of tls eramirathn on &is dny, l approre this 6itd's pors

PELSIC.{LEDUC-&TIaN Yes tr No tr Modffied tr INTE&scEoLA$TtCSpoRTSforoneycar) yestr Ho;1 lfui;eg trPhysician/Adrmced Pracrice l6nser?hysiciar Assistanr ptrtbmliq eiamiauion

PrintName $e, Ilaae

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(Complete both sides)