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It collects identifying details, birth information, sex, race/ethnicity, and school grade data, then captures health history including allergies, asthma, developmental or blood disorders, diabetes, seizures, injuries, and TB status. 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It also includes a section for recommended but not required vaccines and provider comments.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},537736,1791667778,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":24,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24},962090893057,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","# Certificate of Child Health Examination\n\n\n| Student's Name   |  |  |  |  |  |  | Birth Date  \u003Cbr>(Mo/Day/Yr)   |  |  | Sex   | Race/Ethnicity   |  | School/Grade Level/ID\\#   |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First  \u003Cbr>Middle  \u003Cbr>Last   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| City  \u003Cbr>ZIP Code  \u003Cbr>Street Address   |  |  |  |  |  |  | Telephone(home/work)  \u003Cbr>Parent/Guardian   |  |  |  |  |  |  |  |  |\n| HEALTH HISTORY:MUST BE COMPLETED AND SIGNED BY PARENT/GUARDIANAND VERIFIED BYHEALTH CARE PROVIDER   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| ALLERGIES  \u003Cbr>(Food,drug,insect,other)   | □Yes  \u003Cbr>□No   |  | List:   |  |  |  |  |  | MEDICATION  \u003Cbr>(Prescribed or taken on a  \u003Cbr>regular basis)   |  |  | □Yes  \u003Cbr>□No   | List:   |  |  |\n| Diagnosis of Asthma?   |  |  |  | □Yes□No   |  |  |  |  |  | Loss of function of one of paired  \u003Cbr>organs?(eye/ear/kidney/testicle)   |  |  |  | □Yes □No   |  |\n| Child wakes during night coughing?   |  |  |  | □Yes□No   |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | Hospitalization?  \u003Cbr>When?What for?   |  |  |  | □Yes □No   |  |\n| Birth Defects?   |  |  |  | □No  \u003Cbr>□Yes   |  |  |  |  |  |  |  |  |  |  |  |\n| Developmental delay?   |  |  |  | □Yes  \u003Cbr>□No   |  |  |  |  |  | Surgery?(List all)  \u003Cbr>When?What for?   |  |  |  | □No  \u003Cbr>]Yes   |  |\n| Blood disorder?Hemophilia,Sickle CellOther?Explain.   |  |  |  | □No  \u003Cbr>□Yes   |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | Serious injury or illness?   |  |  |  | No  \u003Cbr>Yes   |  |\n| Diabetes?   |  |  |  | □No  \u003Cbr>□Yes   |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | TB skin test positive(past/present)?   |  |  |  | No  \u003Cbr>Yes*   | *f yes,refer tolocal  \u003Cbr>health department   |\n| Head injury/Concussion/Passed out?   |  |  |  | □No  \u003Cbr>□Yes   |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | TB disease(past or present)?   |  |  |  | □No  \u003Cbr>□Yes*   |  |\n| Seizures?What are they like?   |  |  |  | □Yes□No   |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | Tobacco use(type,frequency)?   |  |  |  | No  \u003Cbr>□Yes   |  |\n| Heart problem/Shortness of breath?   |  |  |  | □Yes  \u003Cbr>□No   |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | Alcohol/Drug use?   |  |  |  | No  \u003Cbr>□Yes   |  |\n| Heart murmur/High blood pressure?   |  |  |  | □Yes□No   |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  | Family history of sudden death  \u003Cbr>before age 50?(Cause?)   |  |  |  | No  \u003Cbr>□Yes   |  |\n| Dizziness or chest pain with exercise?   |  |  |  | □Yes□No   |  |  |  |  |  |  |  |  |  |  |  |\n| □Glasses □Contacts Last exam by eye doctor  \u003Cbr>Eye/Vision problems?   |  |  |  |  |  |  |  |  |  | □Other  \u003Cbr>Plate  \u003Cbr>Bridge  \u003Cbr>Braces  \u003Cbr>Dental   |  |  |  |  |  |\n| Other concerns?(Crossed eye,drooping lids,squinting,difficulty reading)   |  |  |  |  |  |  |  |  |  | Additional Information:   |  |  |  |  |  |\n| Ear/Hearing problems?   |  |  |  | □No  \u003Cbr>□Yes   |  |  |  |  |  | Information may be shared with appropriate personnel for health and educationalpurposes.  \u003Cbr>Parent/Guardian  \u003Cbr>Signatures:  \u003Cbr>Date:   |  |  |  |  |  |\n| Bone/Joint problem/injury/scoliosis?   |  |  |  | □Yes□No   |  |  |  |  |  |  |  |  |  |  |  |\n| IMMUNIZATIONS:To be completed by health care provider.The mo/day/yr for every dose administered is required.If a specific vaccine is medically  \u003Cbr>contraindicated,a separate written statement must be attached by the health care provider responsible for completing the health examination  \u003Cbr>explaining the medical reason for the contraindication.   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| REQUIRED  \u003Cbr>Vaccine/Dose   |  | DOSE 1  \u003Cbr>MO DA YR   |  |  | DOSE 2  \u003Cbr>MO DA YR   |  |  | DOSE 3  \u003Cbr>MO DA YR   |  |  | DOSE 4  \u003Cbr>MO DA YR   |  | DOSE 5  \u003Cbr","cbCaibtIsEKFqsWK","https://ap.wps.com/l/cbCaibtIsEKFqsWK","pdf",1010959,"English","# Student Information\n# Health History\n## Allergies and Medications\n## Medical Conditions and Screening\n# Immunizations\n## Required Vaccines and Doses\n## Recommended Vaccines (Not Required)\n# Provider Verification","[{\"question\":\"Who is required to complete and sign the Health History section?\",\"answer\":\"The form states that health history must be completed and signed by the parent or guardian, then verified by the health care provider.\"},{\"question\":\"What kinds of health issues are captured in the health history?\",\"answer\":\"The form includes items such as allergies, asthma, sleep coughing, hospitalization, birth defects, developmental delay, blood disorders, diabetes, seizures, heart problems, dizziness/chest pain with exercise, and TB test or disease status.\"},{\"question\":\"How are immunizations recorded on this form?\",\"answer\":\"Immunizations list required vaccines and their doses, with a required month/day/year for each dose administered. It also includes a section for recommended but not required vaccines and provider comments.\"}]","Certificate of Child Health Examination - Health History and Immunization Form | PDF",1791605293]