Health Forms
Health Requirements
General
Download general forms to support a student’s health needs. Due upon enrollment, a Physical Examination must be completed within one year prior to entry for all PK, K, 6th, 9th graders and any students entering CPS for the first time.
- State of Illinois Certificate of Child Health Exam [ ENGLISH ]
- SY25-26 Student Medical Information Form [ ENGLISH | SPANISH ]
- Medical Report [ ENGLISH ]
- Referral for Suspected Illness [ ENGLISH ]
- Physician’s Report on Student with Major Health Problem (Major Medical PHC 60) [ ENGLISH ]
- Shunt Precautions Form [ ENGLISH ]
- Homebound Services (Referral for Adjustment of Educational Program) [ ENGLISH ]
- Consent for Release/Exchange of Student Records and Information [ ENGLISH | SPANISH ]
(All students with a medical condition are encouraged to complete this form so that the school so that the school can communicate with your medical provider)
Medication Administration
The following forms allow students to receive their medication under adult supervision at school. With the appropriate forms, students are permitted to carry and self-administer asthma, diabetes, seizure, or allergy medication.
Allergies
Documenting your student’s allergies at school ensures proper support is provided for your student. A health care provider should complete these forms and any needed Medication Administration forms.
- Physician Report on Child with Allergies [ ENGLISH ]
- Food Allergy Action Plan [ ENGLISH | SPANISH ]
- Physician Statement for Food Substitution [ ENGLISH | SPANISH ]
- Physician’s Request for Student to Carry an EpiPen [ ENGLISH ]
- Physician Request for Self-Administration of Medication [ ENGLISH ]
- Parent Request for Self-Administration of Medication [ ENGLISH | SPANISH ]
- Physician Request for Administration of Medication [ ENGLISH ]
- Parent Request for Administration of Medication to a Student [ ENGLISH | SPANISH ]
Asthma
Documenting your student’s asthma at school ensures proper support is provided for your student. A healthcare provider should complete these forms and any needed Medication Administration forms.
- Physician Report on Child with Asthma [ ENGLISH ]
- Asthma Action Plan [ ENGLISH ]
- Physician’s Request for Student to Carry Inhaler on Person [ ENGLISH ]
- Physician Request for Self-Administration of Medication [ ENGLISH ]
- Parent Request for Self-Administration of Medication [ ENGLISH | SPANISH ]
- Physician Request for Administration of Medication [ ENGLISH ]
- Parent Request for Administration of Medication to a Student [ ENGLISH | SPANISH ]
Cardiac Condition
Documenting your student’s cardiac condition at school ensures they are given the proper support. A healthcare provider should complete this form and any needed Medication Administration forms.
- Physician’s Report of Child with Cardiac Condition [ ENGLISH ]
- Physician Request for Self-Administration of Medication [ ENGLISH ]
- Parent Request for Self-Administration of Medication [ ENGLISH | SPANISH ]
- Physician Request for Administration of Medication [ ENGLISH ]
- Parent Request for Administration of Medication to a Student [ ENGLISH | SPANISH ]
Dental
Diabetes
Documenting your student’s diabetes at school ensures they are given the proper support. A healthcare provider should complete this form and any needed Medication Administration forms.
- Physician Report on Child with Diabetes [ ENGLISH ]
- Physician Request for Self-Administration of Medication [ ENGLISH ]
- Parent Request for Self-Administration of Medication [ ENGLISH | SPANISH ]
- Physician Request for Administration of Medication [ ENGLISH ]
- Parent Request for Administration of Medication to a Student [ ENGLISH | SPANISH ]
Neurodivergent
- Report on a Student with a Neurodivergent Condition [ ENGLISH ]
Physical or Occupational Therapy
All students receiving physical or occupational therapy services are requested to provide a completed form signed by their medical provider each school year.
- Physician’s Referral for Physical or Occupational Therapy [ ENGLISH ]
Pregnancy
School nurses can use the following form to monitor student pregnancy.
- Pregnancy Monitoring [ ENGLISH ]
Seizures
Documenting your student’s seizure at school ensures they are given the proper support. A healthcare provider should complete these forms and any needed Medication Administration forms.
- Physician Report on Child with a Neurological Disorder [ ENGLISH ]
- Seizure Action Plan [ ENGLISH ]
- Physician Request for Self-Administration of Medication [ ENGLISH ]
- Parent Request for Self-Administration of Medication [ ENGLISH | SPANISH ]
- Physician Request for Administration of Medication [ ENGLISH ]
- Parent Request for Administration of Medication to a Student [ ENGLISH | SPANISH ]
Sports
A healthcare provider should complete this form for students participating in school sports. Sports physicals expire after 13 months.
- Sports Physical – Pre-participation Examination [ ENGLISH ]
Vision
Download vision examination forms below. Vision exams are required for students entering Kindergarten or entering Illinois schools for the first time at any grade level.
Need to Find a Health Center?
Use the Find a Health Center map to find a Federally Qualified Health Center near you. Health Centers can provide you and your family with comprehensive, culturally competent, high-quality primary health care services as well as supportive services such as health education, translation, and transportation that promote access to health care. Federally Qualified Health Centers provide services regardless of a patient’s ability to pay and charge for services on a sliding fee scale.
