skin test positive (past/present)? Yes* Seizures? What are they like? Yes No TB disease (past or present)? Yes* No *If yes, refer to local health department. No Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No Family history of sudden death before age 50? (Cause?) Yes No Yes No Dizziness or chest pain with exercise? Eye/Vision problems? _____ Glasses Contacts Last exam by eye .
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How to fill out the IL IL444-4737 online
Filling out the IL IL444-4737 form is essential for maintaining accurate health records for children in licensed child care facilities. This guide provides a clear and structured approach to completing the form online, ensuring you have the necessary information ready and know how to navigate each section.
Follow the steps to accurately complete the IL IL444-4737 online.
- Click ‘Get Form’ button to obtain the form and open it in your editor.
- Begin by entering the student's personal information, including their name, birth date, and address. Ensure that you provide accurate details as these will be referenced for health records.
- Fill in the parent or guardian's information, including their name and contact numbers. This ensures that proper communication can occur regarding the child's health.
- Complete the immunization section as outlined, ensuring that the dates for each vaccine administered are accurately recorded. This should be done by a licensed health care provider.
- If applicable, indicate any alternative proof of immunity. Ensure appropriate supporting documents such as lab results or medical records are ready to be attached if required.
- The health care provider must sign and date the form, verifying the immunizations recorded. This adds credibility to the health records being submitted.
- Proceed to complete the health history section. Gather information about allergies, medications, hospitalizations, and any previous health conditions relevant to the child's health.
- Fill in any additional assessments and screenings such as vision and hearing that may have been conducted, ensuring all occurrences are documented accurately.
- Finally, review all entries for accuracy and completeness before saving your changes. You may then download, print, or share the form as needed.
Complete your IL IL444-4737 document online today to ensure your child's health records are up-to-date.
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IL444-4737 (R-01-12). (COMPLETE BOTH SIDES). Printed by Authority of the State of...
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