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District of Columbia Child Health Certificate Form

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District of Columbia Child Health Certificate Form
District of Columbia Child Health Certificate Form
CONFIDENTIAL FORM-SIDE ONE PLEASE REVIEW INSTRUCTIONS ON SIDE TWO
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Part 1: Child’s Personal Information Parent/Guardian: Please complete Part 1 clearly and completely & sign Part 6 below.
Child’s Last Name Child’s First & Middle Name Date of Birth Gender:
M
F
Race/Ethnicity:
White Non Hispanic
Black Non Hispanic
Hispanic
Asian or Pacific Islander
Other______________
Parent or Guardian Name Telephone1:
Home
Cell
Work
Home Address: Ward
Emergency Contact: Telephone2:
Home
Cell
Work
City/State
(if other than D.C.)
Zipcode:
School or child care facility:
Medicaid
Private Insurance
None
Other ________________________________
Primary Care Provider (PCP):
Part 2: Child’s Health History, Examination & Recommendations. Health Provider: Form must be fully completed.
DATE OF HEALTH EXAM: WT LBS
KG
HT IN
CM
BP:
(>3 yrs)
NML
ABNL
HGB / HCT
(Required for Head Start)
HEALTH CONCERNS: REFERRED or TREATED HEALTH CONCERNS: REFERRED or TREATED
Dental-Oral Health None YES Referred Under Rx Language/Speech None YES Referred Under Rx
Asthma None YES Referred Under Rx Vision None YES Referred Under Rx
Development None YES Referred Under Rx Hearing None YES Referred Under Rx
Behavioral/Emotional None YES Referred Under Rx Nutrition None YES Referred Under Rx
Learning/Attention None YES Referred Under Rx Neurologic None YES Referred Under Rx
ANNUAL DENTIST VISIT: (Age 3 and older): Has the child seen a Dentist/Dental Provider within the last year YES NO Referred
A. Significant health history, conditions, communicable illness, or restrictions that may affect school, childcare, sports, or camp.
NONE YES, please detail:
_______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
B. Significant allergies or health conditions that may require emergency medical care at school, childcare, camp, or sports activity.
NONE YES, please detail:
_______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
C. Long-term Medications or special care requirements or accommodations.
NONE YES, please detail:
(Please specify medication dosage/time/administration instructions and common side effects if given at school/child care)
_______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
This child has been appropriately examined & health history reviewed. At time of exam, this child is in satisfactory health to participate in all
school, camp or childcare activities except as noted above. ATHLETE IS CLEARED FOR COMPETITIVE SPORTS: YES NO
Part 3: Immunization Information: (Please fill in or attach equivalent copy with provider signature and date)
Diphtheria-Tetanus-Pertussis (< 7 yrs)
DTP/DTaP-1 DTP/DTaP-2 DTP/DTaP-3 DTP/DTaP-4 DTP/DTaP-5
Diphtheria-Tetanus
(DT <7 yrs must have P exemption) (Td >7
yrs)
DT/Td -1 DT/Td -2 DT/Td –3 DT/Td -4 DT/Td-5
Hemophilus Influenzae B (HIB)
HIB1
HIB2
HIB3
HIB4
Hepatitis B (HBV)
HBV1
HBV2
HBV3
Polio
OPV/IPV- 1 OPV/IPV- 2 OPV/IPV-3 OPV/IPV- 4
Measles-Mumps-Rubella (MMR)
MMR1
MMR2
Measles-1____________
Measles-2____________
Mumps-1____________
Mumps-2____________
Rubella-1____________
Rubella-2____________
Varicella
VZV1 VZV2
Check if hx disease
Disease date ____________________
Influenza (not required)
FLU-1 FLU-2 FLU-3 FLU-4 FLU-5
Pneumococcal conjugate (PCV7)
PCV7-1
PCV7-2
PCV7-3
PCV7-4
Other
Part 4: Tuberculosis & Lead Exposure Risk Assessment & Testing If PPD Positive:
TB EXPOSURE RISKS
See reverse side for instructions.
HIGHÆ
LOW
PPD TEST DATE:
NEGATIVE
POSITIVE
CXR NEGATIVE
CXR POSITIVE
TREATED
Health Provider: ALL POSITIVE
PPD tests MUST BE Reported to
T.B. Control: 202-698-4040
LEAD EXPOSURE RISKS
See reverse side for instructions.
YESÆ
NO
LEAD TEST DATE:
RESULT:
Health Provider: ALL lead levels MUST BE Reported to DC Division of
Lead Poisoning Prevention: Fax: 202-535-1398
Part 5: Required Provider Certification and Signature
Age-Appropriate Health Screening Requirements Performed Within Current Year YES NO
If NO, please explain
________________________________________________________________________________________________________________________
Medical Exemption From Immunization: I hereby certify that the student named above was not immunized against (disease) ___________________
because (reason) _______________________________________ (if applicable, attach serological test results). Date Exemption Expires: __________
Print Name
MD/NP Signature
Date
Address
Phone Fax
Part 6: Required Parental/Guardian Signatures. (Release of Health Information)
I give permission to the signing health examiner/facility to share the health information on this form with my child’s school, childcare, camp, or DOH
PRINT NAME
SIGNATURE Date
Top Copy – School Nurse 2nd Copy – School 3rd Copy – Parent 5/17/04
District of Columbia Child Health Certificate Form
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