Form Ch-205 - Child & Adolescent Health Examination Form printable pdf download

CHILD & ADOLESCENT HEALTH EXAMINATION FORM

Please

STUDENT ID NUMBER

Print Clearly

OSIS

NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE

—

DEPARTMENT OF EDUCATION

Press Hard

TO BE COMPLETED BY PARENT OR GUARDIAN

Child’s Last Name

First Name

Middle Name

Sex

Female

Date of Birth

)

(Month/Day/Year

Male

__ __ / ___ ___ / ___ ___ ___ ___

Child’s Address

Hispanic/Latino?

Race

American Indian

Asian

Black

White

(Check ALL that apply)

Yes

Native Hawaiian/Pacific Islander

Other ____________________________

Phone Numbers

City/Borough

State

Zip Code

School/Center/Camp Name

District

__ __

Number __ __ __

_____________________

Home

______________________

Health insurance

Yes

Parent/Guardian Last Name

First Name

Cell

(including Medicaid)?

Foster Parent

______________________

Work

TO BE COMPLETED BY HEALTH CARE PROVIDER

If “yes” to any item, please explain (attach addendum, if needed)

Birth history

Does the child/adolescent have a past or present medical history of the following?

(age 0-6 yrs)

Asthma

Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent

(check severity and attach MAF/Asthma Action Plan):

Uncomplicated

Premature: ________ weeks gestation

Inhaled corticosteriod

Other controller

Quick relief med

Oral steroid

None

If persistent, check all current medication(s):

Complicated by

_______________________________

Attention Deficit Hyperactivity Disorder

Orthopedic injury/disability

Medications

(attach MAF if in-school medication needed)

Chronic or recurrent otitis media

Seizure disorder

Allergies

None

Epi pen prescribed

None

Yes

(list below)

Congenital or acquired heart disorder

Speech, hearing, or visual impairment

Drugs

(list)

Developmental/learning problem

Tuberculosis

(latent infection or disease)

Diabetes

Other

___________________

(attach MAF)

(specify)

Foods

(list)

Dietary Restrictions

None

Yes

(list below)

Other

(list)

Explain all checked items above or on addendum

PHYSICAL EXAMINATION

General Appearance:

Height ____________________ cm

( ___ ___ %ile)

Nl Abnl

HEENT

Lymph nodes

Abdomen

Skin

Psychosocial Development

Weight ____________________ kg

( ___ ___ %ile)

Dental

Lungs

Genitourinary

Neurological

Language

BMI

____________________ kg/m

( ___ ___ %ile)

Neck

Cardiovascular

Extremities

Back/spine

Behavioral

Describe abnormalities:

(age ≤2 yrs)

Head Circumference

______________ cm ( ___ ___ %ile)

(age ≥3 yrs)

Blood Pressure

_________ / __________

Date Done

Results

SCREENING TESTS

DEVELOPMENTAL

Within normal limits

Date Done

Results

(age 0-6 yrs)

Blood Lead Level (BLL)

Tuberculosis

If delay suspected, specify below

Only required for students entering intermediate/middle/junior or high school

_________ µg/dL

__ __ / ___ ___ / ___ ___

who have not previously attended any NYC public or private school

(required at age 1 yr and 2 yrs

Cognitive

_________ µg/dL

and for those at risk)

(e.g., play skills) ____________________________

__ __ / ___ ___ / ___ ___

PPD/Mantoux placed

Induration ______mm

__ __ / ___ ___ / ___ ___

Lead Risk Assessment

At risk

(do BLL)

PPD/Mantoux read

Neg

Pos

__ __ / ___ ___ / ___ ___

(annually, age 6 mo-6 yrs)

Communication/Language

_________________________

Not at risk

__ __ / ___ ___ / ___ ___

Interferon Test

Neg

Pos

__ __ / ___ ___ / ___ ___

Hearing

Social/Emotional

__________________________________

Pure tone audiometry

Normal

Chest x-ray

Not

OAE

Abnormal

__ __ / ___ ___ / ___ ___

Abnl

Indicated

(if PPD or Interferon positive)

Adaptive/Self-Help

__ __ / ___ ___ / ___ ___

________________________________

—— Head Start Only ——

Vision

Acuity

___ / ___

Right

Hemoglobin or

__________ g/dL

Motor

___________________________________________

(required for new school entrants

___ / ___

Left

Hematocrit

(age 9–12 mo)

__ __ / ___ ___ / ___ ___

__________ %

__ __ / ___ ___ / ___ ___

and children age 4–7 yrs)

with glasses

Strabismus

Yes

IMMUNIZATIONS – DATES

CIR Number

Influenza

of Child

__ __ / ___ ___ / ___ ___

Hep B

__ __ / ___ ___ / ___ ___

MMR

__ __ / ___ ___ / ___ ___

Rotavirus

__ __ / ___ ___ / ___ ___

Varicella

__ __ / ___ ___ / ___ ___

DTP/DTaP/DT

__ __ / ___ ___ / ___ ___

Tdap

Hep A

__ __ / ___ ___ / ___ ___

Hib

__ __ / ___ ___ / ___ ___

Meningococcal

__ __ / ___ ___ / ___ ___

PCV

__ __ / ___ ___ / ___ ___

HPV

__ __ / ___ ___ / ___ ___

Polio

__ __ / ___ ___ / ___ ___

Other, s

____________

_______________

pecify:

__ __ / ___ ___ / ___ ___ ;

__ __ / ___ ___ / ___ ___

RECOMMENDATIONS

Full physical activity

Full diet

ASSESSMENT

Well Child (V20.2)

Diagnoses/Problems

ICD-9 Code

(list)

Restrictions (

specify) ___________________________________________________________________________

_____________________________________________________________

__ __ __ __ __

Follow-up Needed

Yes, for _________________________ Appt. date:

__ __ / ___ ___ / ___ ___

_____________________________________________________________

__ __ __ __ __

Referral(s):

None

Early Intervention

Special Education

Dental

Vision

Other

________________________________________________________________________

_____________________________________________________________

__ __ __ __ __

PROVIDER

DOHMH

Health Care Provider Signature

Date

ONLY

I.D.

__ __ / ___ ___ / ___ ___

Health Care Provider Name and Degree

Provider License No. and State

(print)

TYPE OF EXAM:

NAE Current

NAE Prior Year(s)

Comments

Facility Name

National Provider Identifier (NPI)

Address

City

State

Zip

I.D. NUMBER

Date

Reviewed:

__ __ / ___ ___ / ___ ___

Telephone

Fax

REVIEWER:

( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___

CH-205 (5/08)

Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian

Form Ch-205 - Child & Adolescent Health Examination Form

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