Illinois requires a physical exam within one year before a child enters school, including preschool, kindergarten or first grade, sixth grade, ninth grade and transfers from another state or country, at public, private and parochial schools alike. This two-page certificate is the form providers complete for that exam, recording the health history, immunizations, screenings and physical findings, and the family hands it to the school or child care facility.
The parent or guardian completes and signs the health history, which the health care provider verifies. A provider (MD, DO, APN, PA, school health professional or health official) verifies and signs the immunization history, and the entire physical examination section must be completed by an MD, DO, APN or PA.
The parent answers yes or no for allergies, regular medication, asthma and night cough, birth defects, hospitalization, surgery, developmental delay, blood disorders, diabetes, seizures, heart problems, head injury, positive TB test or TB disease, tobacco and alcohol or drug use, family history of sudden death before 50, vision, dental and hearing issues, and signs the section. The provider verifies it. A yes to positive TB test or TB disease means referral to the local health department.
Enter the month, day and year of every dose of each required vaccine: DTP or DTaP, Tdap, Td or pediatric DT, polio (IPV or OPV), Hib, pneumococcal conjugate, hepatitis B, MMR, varicella and meningococcal conjugate. Recommended vaccines such as hepatitis A, HPV and influenza have their own rows. If a vaccine is medically contraindicated, attach a separate written statement explaining the reason. Initial any dates you add and sign.
Three options replace vaccine dates. A clinical diagnosis of measles, mumps or hepatitis B, verified by a physician and supported by an attached lab result. A history of varicella disease, verified and signed by a health care provider, school health professional or health official. Or laboratory evidence of immunity to measles, mumps, rubella or varicella, with the lab result attached. Measles cases since July 1, 2002 and mumps cases since July 1, 2013 need lab confirmation.
Record head circumference if the child is under 2 to 3 years, height, weight, BMI, BMI percentile and blood pressure. Diabetes screening, not required for day care, asks whether BMI is above the 85th percentile for age and sex plus any two of family history, ethnic minority, or signs of insulin resistance such as hypertension, dyslipidemia, polycystic ovarian syndrome or acanthosis nigricans, then whether the child is at risk.
The lead questionnaire is required for children aged 6 months through 6 years in licensed or school-run day care, preschool, nursery school or kindergarten; a blood test is required for children living in Chicago or a high-risk ZIP code. Record whether a blood test was indicated, with date and result. TB testing is recommended only for high-risk children; mark no test needed or record the skin test reading in millimeters or the blood test result.
Recommended lab tests are hemoglobin or hematocrit, urinalysis and sickle cell testing when indicated, each with date and result. Under Screenings, record whether a developmental screening and a social and emotional screening were completed, or N/A. IDPH says only whether the screening was done goes on the form; results are not recorded and may be shared with the school only with written parent consent.
Mark each system normal or add comments and follow-up needs: skin, ears and eyes with screening results, nose, throat, mouth and dental, cardiovascular and hypertension, respiratory, endocrine, gastrointestinal, genitourinary with LMP, neurological, musculoskeletal, spinal exam, nutritional status and mental health. If asthma is diagnosed, check the currently prescribed quick-relief medication, such as a short-acting beta agonist, controller medication, such as an inhaled corticosteroid, or other.
List needs or modifications required in the school setting and dietary needs or restrictions, then special instructions or devices such as safety glasses, a pacemaker, a prosthetic device or an athletic cup. Note anything else the school should know, and check nurse, teacher, counselor or principal if you would like to discuss the student. Answer whether emergency action may be needed at school, for example for seizures, asthma, food allergy or diabetes, and describe it.
On the basis of that day's exam, approve the child's participation in physical education and in interscholastic sports as yes, no or modified, attaching an explanation for no or modified. IDPH notes the certificate may be accepted as proof of a sports exam only when this interscholastic sports statement is completed. Print your name, check MD, DO, APN or PA, sign and date, and add address and phone.
Download the current version from the source each time; forms change without notice.
Certificate of Child Health Examination
Certificado de Examen de Salud Infantil
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Sources for this guide
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The physical examination section must be completed by an MD, DO, APN or PA, who prints their name, checks their credential and signs. The immunization history can be verified and signed by an MD, DO, APN, PA, school health professional or health official, and anyone adding vaccine dates initials each one. The parent or guardian signs the health history.
IDPH says the health examination is valid within one year prior to entering school. Exams are required before entering school or preschool, kindergarten or first grade, sixth grade and ninth grade, and for students transferring from another state or country. The form records the exam date beside the provider's signature.
Yes. IDPH posts the Spanish version, titled Certificado de Examen de Salud Infantil, on its School Health Program page next to the English form. IDPH asks providers to use the version on its website to be sure they have the current approved form.
Yes. IDPH's provider update says practices may update electronic versions of the certificate in their electronic health record system and that IDPH does not require a review of the update. The EHR version should match the current form, which adds the social-emotional and developmental screening line required for exams after January 1, 2025.