Universal Health Certificate - DC...

Department of Health | 899 North Capitol Street, N.E., Washington, DC 20002 | 202.442.5925 | dchealth.dc.gov version 03.13.19 pg1

Universal Health Certificate

Use this form to report your child’s physical health to their school/child care facility which is required by DC Official Code §38-602. Have a licensed medical professional complete part 2 - 4.

Part 1: Child Personal Information | To be completed by parent/guardian. Child Last Name: Child First Name: Date of Birth:

School or Child Care Facility Name: Gender: Male Female Non-Binary

Home Address: Apt: City: State: ZIP: Ethnicity: (check all that apply) Hispanic/Latino Non-Hispanic/Non-Latino Other Prefer not to answer Race: (check all that apply) American Indian/

Alaska Native Asian Native Hawaiian/

Pacific Islander Black/African

American White Prefer not

to answer

Parent First Name: Parent Last Name: Parent Phone:

Emergency Contact Name: Emergency Contact Phone:

Insurance Type: Medicaid Private None Insurance Name/ID #:

Has the child seen a dentist/dental provider within the last year? Yes No I give permission to the signing health examiner/facility to share the health information on this form with my child’s school, child care, camp, or appropriate DC Government agency. In addition, I hereby acknowledge and agree that the District, the school, its employees and agents shall be immune from civil liability for acts or omissions under DC Law 17-107, except for criminal acts, intentional wrongdoing, gross negligence, or willful misconduct. I understand that this form should be completed and returned to my child’s school every year.

Parent/Guardian Signature: _______________________________________________ Date: ____________________

Part 2: Child’s Health History, Exam, and Recommendations | To be completed by licensed health care provider. Date of Health Exam: BP:

____ /_____ NML Weight: LB Height: IN BMI: BMI

Percentile: ABNL KG CM

Vision Screening: Left eye: 20/________ Right eye: 20/________ Corrected

Uncorrected Wears glasses Referred Not tested

Hearing Screening: (check all that apply) Pass Fail Not tested Uses Device Referred

Does the child have any of the following health concerns? (check all that apply and provide details below)

Asthma

Autism

Behavioral

Cancer

Cerebral palsy

Development

Diabetes

Failure to thrive

Heart failure

Kidney Failure

Language/Speech

Obesity

Scoliosis

Seizures

Sickle Cell

Significant food/medication/environmental allergies that may require emergency medical care. Details provided below.

Long-term medications, over-the-counter-drugs (OTC) or special care requirements. Details provided below.

Significant health history, condition, communicable illness, or restrictions. Details provided below.

Other:_________________________________________________________________ Provide details. If the child has Rx/treatment, please attach a complete Medication/Medical Treatment Plan form; and if the child was referred, please note. _______________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

TB Assessment | Positive TST should be referred to Primary Care Physician for evaluation. For questions call T.B. Control at 202-698-4040. What is the child’s risk level for TB?

High complete skin test and/or Quantiferon test

Low

Skin Test Date: Quantiferon Test Date: Skin Test Results: Negative Positive, CXR Negative Positive, CXR Positive Positive, Treated

Quantiferon Results: Negative Positive Positive, Treated

Additional notes on TB test:

Lead Exposure Risk Screening | All lead levels must be reported to DC Childhood Lead Poisoning Prevention. Call 202-654-6002 or Fax: 202-535-2607 ONLY FOR CHILDREN UNDER AGE 6 YEARS Every child must have 2 lead tests by age 2

1st Test Date: 1st Result: Normal Abnormal, Developmental Screening Date:

1st Serum/Finger Stick Lead Level:

2nd Test Date: 2nd Result: Normal Abnormal, Developmental Screening Date:

2nd Serum/Finger Stick Lead Level:

HGB/HCT Test Date: HGB/HCT Result:

Department of Health | 899 North Capitol Street, N.E., Washington, DC 20002 | 202.442.5925 | dchealth.dc.gov version 03.13.19 pg2

Part 3: Immunization Information | To be completed by licensed health care provider. Immunizations Provide in the boxes below the dates of Immunization (MM/DD/YY)

Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5

DT (<7 yrs.)/ Td (>7 yrs.) 1 2 3 4 5

Tdap Booster 1

Haemophilus influenza Type b (Hib) 1 2 3 4

Hepatitis B (HepB) 1 2 3 4

Polio (IPV, OPV) 1 2 3 4

Measles, Mumps, Rubella (MMR) 1 2

Measles 1 2

Mumps 1 2

Rubella 1 2

Varicella 1 2 Child had Chicken Pox (month & year):

Pneumococcal Conjugate 1 2 3 4

Hepatitis A (HepA) (Born on or after 01/01/2005)

1 2

Meningococcal Vaccine 1 2

Human Papillomavirus (HPV) 1 2 3

Influenza (Recommended) 1 2 3 4 5 6 7

Rotavirus (Recommended) 1 2 3

The child is behind on immunizations and there is a plan in place to get him/her back on schedule. Next appointment is: _________________

Medical Exemption (if applicable) I certify that the above child has a valid medical contraindication(s) to being immunized at the time against:

Diphtheria Tetanus Pertussis Hib HepB Polio Measles

Mumps Rubella Varicella Pneumococcal HepA Meningococcal HPV Alternative Proof of Immunity (if applicable) I certify that the above child has laboratory evidence of immunity to the following and I’ve attached a copy of the titer results.

Diphtheria Tetanus Pertussis Hib HepB Polio Measles

Mumps Rubella Varicella Pneumococcal HepA Meningococcal HPV

Part 4: Licensed Health Practitioner’s Certifications| To be completed by licensed health care provider. This child has been appropriately examined and health history reviewed and recorded in accordance with the items specified on this form. At the time of the exam, this child is in satisfactory health to participate in all school, camp, or child care activities except as noted on page one.

No Yes

This child is cleared for competitive sports. Additional clearance(s) needed from:

___________________________________________________________________ N/A No Yes Yes, pending additional

clearance

I hereby certify that I examined this child and the information recorded here was determined as a result of the examination.

Licensed Health Care Provider Office Stamp Provider Name:

Provider Phone:

Provider Signature:

Date:

Access health insurance programs at https://dchealthlink.com. You may contact the Health Suite Personnel through the main office at your child’s school.

OFFICE USE ONLY | Universal Health Certificate received by School Official and Health Suite Personnel.

School Official Name: Signature: Date: Health Suite Personnel Name: Signature: Date:

Oral Health Assessment Form For all students aged 3 years and older, use this form to report their oral health status to their school/child care facility.

Instructions • Complete Part 1 below. Take this form to the student's dental provider. The dental provider should complete Part 2. • Return fully completed and signed form to the student's school/child care facility.

Part 1: Student Information (To be completed by parent/guardian)

First Name _____________________________ Last Name _____________________________ Middle Initial ______ School or Child Care Facility Name_____________________________________

Date of Birth (MMDDYYYY) Home Zip Code

Grade School Grade

Day-care Pre-K3 Pre-K4 1 2 3 4 5 6 7 8 9 10 11 12

Adult Ed.

Part 2: Student's Oral Health Status (To be completed by the dental provider)

Q1 Does the patient have at least one tooth with apparent cavitation (untreated caries)? This does NOT include stained pit or fissure that has no apparent breakdown of enamel structure or non-cavitated demineralized lesions (i.e. white spots).

Yes No

Q2 Does the patient have at least one treated carious tooth? This includes any tooth with amalgam, composite, temporary restorations, or crowns as a result of dental caries treatment.

Q3 Does the patient have at least one permanent molar tooth with a partially or fully retained sealant?

Q4 Does the patient have untreated caries or other oral health problems requiring care before his/her routine check-up? (Early care need)

Q5 Does the patient have pain, abscess, or swelling? (Urgent care need)

Q6 How many primary teeth in the patient's mouth are affected by caries that are either untreated or treated with fillings/crowns?

Total Number

Q7 How many permanent teeth in the patient's mouth are affected by caries that are either untreated, treated with fillings/crowns, or extracted due to caries?

Total Number

Q8 What type of dental insurance does the patient have? Medicaid Private Insurance Other None

Dental Provider Name ______________________________ Dental Office Stamp

Dental Provider Signature ____________________________ Dental Examination Date ____________________________

This form replaces the previous version of the DC Oral Health Assessment Form used for entry into DC Schools, all Head Start programs, and child care centers. This form is approved by the DC Health and is a confidential document. Confidentiality is adherent to the Health Insurance Portability and Accountability Act of 1996 (HIPPA) for the health providers and the Family Education Right and Privacy Act (FERPA) for the DC Schools and other providers.

DC Health | 899 North Capitol Street, NE., Washington, DC | 202.535.2180 | dchealth.dc.gov January 2019

Asthma Action PlanName Date of Birth Date

/ /Health Care Provider Provider’s Phone

Parent/Responsible Person Parent’s Phone School

Additional Emergency Contact Contact Phone Last 4 Digits of SS#

GREEN means Go!Use CONTROL medicine daily

YELLOW means Caution!Add RESCUE medicine

RED means EMERGENCY!Get help from a doctor now!

Asthma Severity (see reverse side) Asthma Triggers Identified (Things that make your asthma worse):■ Intermittent orPersistent: ■ Mild ■ Moderate ■ Severe

Asthma Control■ Well-controlled ■ Needs better control

■ Colds ■ Smoke (tobacco, incense) ■ Pollen ■ Dust ■ Animals________■ Strong odors ■ Mold/moisture ■ Pests (rodents, cockroaches)■ Stress/emotions ■ Gastroesophageal reflux ■ Exercise■ Season: Fall, Winter, Spring, Summer ■ Other:______________________ ___ /___ /___

Green Zone: Go!–Take these CONTROL (PREVENTION) Medicines EVERY DayYou have ALL of these:

• Breathing is easy

• No cough or wheeze

• Can work and play

• Can sleep all night

Peak flow in this area:_________ to_________

(More than 80% of Personal Best)

Personal best peak flow:____________

■ No control medicines required. Always rinse mouth after using your daily inhaled medicine.

■ _________________________________________ , ______ puff(s) MDI with spacer_____ times a dayInhaled corticosteroid or inhaled corticosteroid/long-acting β−agonist

■ ___________________________________________ , _____ nebulizer treatment(s)_____ times a dayInhaled corticosteroid

■ ___________________________________________ , take_____ by mouth once daily at bedtimeLeukotriene antagonist

For asthma with exercise, ADD:■ _____________________ , _______ puff(s) MDI with spacer 15 minutes before exercise

Fast-acting inhaled β−agonist

For nasal/environmental allergy, ADD:■ ____________________________________________________________________________________

Yellow Zone: Caution!–Continue CONTROL Medicines and ADD RESCUE MedicinesYou have ANY of these:• First sign of a cold

• Cough or mild wheeze

• Tight chest

• Problems sleeping,working, or playing


(50%-80% of Personal Best)

You have ANY of these:• Can’t talk, eat, or walk well• Medicine is not helping• Breathing hard and fast• Blue lips and fingernails• Tired or lethargic• Ribs show

Peak flow in this area:Less than _________

(Less than 50% of Personal Best)

■ ____________________ , ______ puff(s) MDI with spacer every ______ hours as neededFast-acting inhaled β−agonist

OR

■ ____________________ , ______ nebulizer treatment(s) every ______ hours as neededFast-acting inhaled β−agonist

■ Other__________________________________________________________________

Call your DOCTOR if you have these signs more than two timesa week, or if your rescue medicine doesn’t work!

■ ______________________ , ____ puff(s) MDI with spacer every 15 minutes, for THREE treatmentsFast-acting inhaled β−agonist

OR■ ______________________ , ____ nebulizer treatment every 15 minutes, for THREE treatments


Call your doctor while giving the treatments.

■ Other_________________________________________________________________________________

IF YOU CANNOT CONTACT YOUR DOCTOR: Call 911 for an ambulanceor go directly to the Emergency Department!

Red Zone: EMERGENCY!–Continue CONTROL & RESCUE Medicines and GET HELP!

www.dcasthmapartnership.orgGovernment of theDistrict of ColumbiaVincent C. Gray, Mayor

Date ofLast FluShot:

SCHOOL MEDICATION CONSENT AND PROVIDER ORDER FOR CHILDREN/YOUTH:Possible side effects of rescue medicines (e.g., albuterol) include tachycardia, tremor, and nervousness.Healthcare Provider Initials:____This student is capable and approved to self-administer the medicine(s) named above.____This student is not approved to self-medicate.As the RESPONSIBLE PERSON:

I hereby authorize a trained school employee, if available, to administer medication to thestudent.I hereby authorize the student to possess and self-administer medication.I hereby acknowledge that the District and its schools, employees and agents shall be immunefrom civil liability for acts or omissions under D.C. Law 17-107 except for criminal acts,intentional wrongdoing, gross negligence, or willful misconduct.

Adapted from NAEPP by Children’s National Medical CenterCoordinated by the National Capital Asthma Coalition

This publication was supported in part by a grant from the DC Department of Health AsthmaControl Program, with funds provided by the Cooperative Agreement Number 5U59EH324208-05

from the Centers for Disease Control and Prevention (CDC). Its contents are solely theresponsibility of the authors and do not necessarily represent the official views of the CDC.

Permission to reproduce blank form. Updated March 2011

REQUIRED Healthcare Provider Signature:

____________________________ Date: ____________

REQUIRED Responsible Person Signature:

____________________________ Date: ____________

Follow up with primary doctor in 1 week or:

_______________________ Phone:________________

Government of theDistrict of ColumbiaVincent C. Gray, Mayor

Asthma Action PlanName Date of Birth Date

/ /Health Care Provider Provider’s Phone

Parent/Responsible Person Parent’s Phone School

Additional Emergency Contact Contact Phone Last 4 Digits of SS#

GREEN means Go!Use CONTROL medicine daily

YELLOW means Caution!Add RESCUE medicine

RED means EMERGENCY!Get help from a doctor now!

Asthma Severity (see reverse side) Asthma Triggers Identified (Things that make your asthma worse):■ Intermittent orPersistent: ■ Mild ■ Moderate ■ Severe

Asthma Control■ Well-controlled ■ Needs better control

■ Colds ■ Smoke (tobacco, incense) ■ Pollen ■ Dust ■ Animals________■ Strong odors ■ Mold/moisture ■ Pests (rodents, cockroaches)■ Stress/emotions ■ Gastroesophageal reflux ■ Exercise■ Season: Fall, Winter, Spring, Summer ■ Other:______________________ ___ /___ /___

Green Zone: Go!–Take these CONTROL (PREVENTION) Medicines EVERY DayYou have ALL of these:

• Breathing is easy

• No cough or wheeze

• Can work and play

• Can sleep all night


(More than 80% of Personal Best)

Personal best peak flow:____________

■ No control medicines required. Always rinse mouth after using your daily inhaled medicine.

■ _________________________________________ , ______ puff(s) MDI with spacer_____ times a dayInhaled corticosteroid or inhaled corticosteroid/long-acting β−agonist

■ ___________________________________________ , _____ nebulizer treatment(s)_____ times a dayInhaled corticosteroid

■ ___________________________________________ , take_____ by mouth once daily at bedtimeLeukotriene antagonist

For asthma with exercise, ADD:■ _____________________ , _______ puff(s) MDI with spacer 15 minutes before exercise


For nasal/environmental allergy, ADD:■ ____________________________________________________________________________________

Yellow Zone: Caution!–Continue CONTROL Medicines and ADD RESCUE MedicinesYou have ANY of these:• First sign of a cold

• Cough or mild wheeze

• Tight chest

• Problems sleeping,working, or playing


(50%-80% of Personal Best)

You have ANY of these:• Can’t talk, eat, or walk well• Medicine is not helping• Breathing hard and fast• Blue lips and fingernails• Tired or lethargic• Ribs show

Peak flow in this area:Less than _________

(Less than 50% of Personal Best)

■ ____________________ , ______ puff(s) MDI with spacer every ______ hours as neededFast-acting inhaled β−agonist

OR

■ ____________________ , ______ nebulizer treatment(s) every ______ hours as neededFast-acting inhaled β−agonist

■ Other__________________________________________________________________

Call your DOCTOR if you have these signs more than two timesa week, or if your rescue medicine doesn’t work!

■ ______________________ , ____ puff(s) MDI with spacer every 15 minutes, for THREE treatmentsFast-acting inhaled β−agonist

OR■ ______________________ , ____ nebulizer treatment every 15 minutes, for THREE treatments


Call your doctor while giving the treatments.

■ Other_________________________________________________________________________________

IF YOU CANNOT CONTACT YOUR DOCTOR: Call 911 for an ambulanceor go directly to the Emergency Department!

Red Zone: EMERGENCY!–Continue CONTROL & RESCUE Medicines and GET HELP!

www.dcasthmapartnership.org

Date ofLast FluShot:

SCHOOL MEDICATION CONSENT AND PROVIDER ORDER FOR CHILDREN/YOUTH:Possible side effects of rescue medicines (e.g., albuterol) include tachycardia, tremor, and nervousness.Healthcare Provider Initials:____This student is capable and approved to self-administer the medicine(s) named above.____This student is not approved to self-medicate.As the RESPONSIBLE PERSON:

I hereby authorize a trained school employee, if available, to administer medication to thestudent.I hereby authorize the student to possess and self-administer medication.I hereby acknowledge that the District and its schools, employees and agents shall be immunefrom civil liability for acts or omissions under D.C. Law 17-107 except for criminal acts,intentional wrongdoing, gross negligence, or willful misconduct.

Adapted from NAEPP by Children’s National Medical CenterCoordinated by the National Capital Asthma Coalition

This publication was supported in part by a grant from the DC Department of Health AsthmaControl Program, with funds provided by the Cooperative Agreement Number 5U59EH324208-05

from the Centers for Disease Control and Prevention (CDC). Its contents are solely theresponsibility of the authors and do not necessarily represent the official views of the CDC.

Permission to reproduce blank form. Updated March 2011

REQUIRED Healthcare Provider Signature:

____________________________ Date: ____________

REQUIRED Responsible Person Signature:

____________________________ Date: ____________

Follow up with primary doctor in 1 week or:

_______________________ Phone:________________

Stepwise Approach for Managing Asthma in Children and Adults (from 2007 NAEPP Guidelines)

Criteria apply to all ages unless otherwise indicated

KSIR TNEMRIAPMI

Daytime Symptoms

Nighttime Awakenings

<5 years ≥5 years

Interfer-ence with normal activity

Short-acting beta-agonist use

FEV1 % predicted (n/a in age <5)

Exacerbations requiring oral systemic corticosteroids

Classification of Asthma SEVERITY: TO DETERMINE INITIATION OF LONG-TERM CONTROL THERAPY Consider severity and interval since last exacerbation when assessing risk. Step

Severe Persistent

Throughout the day

>1x/week Often 7x/week

Extremely limited

Several x/day

<60%

<5: ≥2 in 6 months OR ≥4 wheezing episodes in 1 year lasting >1 day AND risk factors for per-sistent asthma 5-adult: ≥2/year

<5: Step 3 5-11: Step 3 Medium-dose ICS option or Step 4 12-adult: Step 4 or 5 All ages: Consider short course OCS

Moderate Persistent

Daily 3-4x/month

>1x/week but not nightly

Some Daily 60-80%

<5: Step 3 5-11: Step 3 Medium-dose ICS option 12-adult: Step 3 All ages: Consider short course OCS

Mild Persistent

>2 days/week but not daily

1-2x/month

3-4x/month

Minor >2 days/week but not daily

>80%

Step 2

Intermittent ≤2 days/week 0 ≤2x/month

None ≤2 days/week

>80%

0-1/year Step 1

Adapted from NAEPP. Please refer to individual drug prescribing information as needed.

CRM: Cromolyn NCM: Nedocromil THE: Theophylline MLK: Montelukast ALT: Alternative

Daily Doses of common inhaled corticosteroids

Fluticasone MDI (mcg)

Low Medium High

Budesonide Respules (mg)

Low Medium High

Beclomethasone MDI (mcg)

Low Medium High

Fluticasone/ Salmeterol

DPI

Budesonide/ Formoterol

MDI

<5 years a/n a/n a/na/n a/n 1> 1-5.0> 5.0-52.0 253> 253-671> 671

5-11 years 88-176 >176-352 >352 0.5 1 2 80-160 >160-320 >320 100/50 mcg 1 inhalation BID

80 mcg/4.5 mcg 2 puffs BID

12 years-adult 88-264 >264-440 >440 n/a n/a n/a 80-240 >240-480 >480 Dose depends on patient Dose depends on patient

Action: In children <5, consider alternate diagnosis or adjusting therapy if no benefit seen in 4-6 weeks.

Very Poorly Controlled

Throughout the day

≥2x/week ≥4x/week Extremely limited

Several times/day

<60%

<5: >3/year 5-adult: ≥2/year

Step up 1-2 steps. Consider short course OCS. Reevaluate in 2 weeks. For side effects, consider alternate treatment.

Not Well Controlled

>2 days/week

≥2x/month

1-3x/week Some >2 days/week

60-80%

<5: 2-3/year 5-adult: ≥2/year

Step up at least 1 step. Reevaluate in 2-6 weeks. For side effects, consider alternate treatment.

Well Controlled

≤2 days/week

≤1x/month

≤2x/month

None ≤2 days/week

>80%

0-1/year Maintain current treatment. Follow-up every 1-6 months. Consider step down if well controlled for at least 3 months.

Classification of Asthma CONTROL: TO DETERMINE ADJUSTMENTS TO CURRENT CONTROL MEDICATIONS Consider severity and interval since last exacerbation and possible medication side effects when assessing risk.

<12 years 12-adult

Step 1 Preferred SABA prn

Step 2

Preferred LD-ICS

Alternative <5: CRM or MLK

5-adult: CRM, LTRA, NCM, or THE

Step 3 Preferred <5: MD-ICS

5-11: EITHER LD-ICS plus LABA, LTRA or THE OR MD-ICS

12-adult: LD-ICS plus LABA OR MD-ICS

Alternative 12-adult: LD-ICS plus either LTRA, THE or Zileuton

Step 4 Preferred <5: Medium-dose ICS plus either LABA or MLK

5-adult: MD-ICS plus LABA

Alternative 5-11: MD-ICS plus either LTRA or THE

12-adult: MD-ICS plus either LTRA, THE or Zileuton

Step 5 Preferred <5: HD-ICS plus either LABA or MLK

5-11: HD-ICS plus LABA

12-adult: High-dose ICS plus LABA AND consider Omalizumab for patients who have allergies

Alternative 5-11: HD-ICS plus either LTRA or THE

Step 6 Preferred <5: HD-ICS plus either LABA or MLK plus OCS

5-11: HD-ICS plus LABA plus OCS

12-adult: HD-ICS plus LABA plus OCS AND consider Omalizumab for patients who have allergies

Alternative 5-11: HD-ICS plus either LTRA or THE plus OCS

Step down if possible (asthma well-controlled at least 3 months)/Step up if needed (check adherence, technique, environment, co-morbidities)

Abbreviations: SABA: Short-acting beta-agonist LABA: Long-acting beta-agonist LTRA: Leukotriene-receptor antagonist ICS: Inhaled corticosteroids LD-ICS: Low-dose ICS MD-ICS: Medium-dose ICS HD-ICS: High-dose ICS OCS: Oral corticosteroids

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