Form Dss-5244 - Child Physical Examination - North Carolina
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1Copy given to________________________________, caregiver, on ____/_____/_____by____________________
CHILD PHYSICAL EXAMINATION
(Please print all information)
Child’s Name ____________________ Date of Birth ____________ Sex ____ Race/Eth.____
County DSS _____________________ Name of Social Worker _________________________
Person Accompanying Child _____________________________________________________
Name of Examining Physician ____________________________________________________
Address____________________________________ Telephone (
) ____________________
PHYSICAL EXAMINATION FINDINGS
Temp _______ Pulse _______ Respirations ________ Blood Pressure ________/___________
Height ___ (
____ Weight _____ (
) ____ Head Circum. ___(
) ____
Percentile)
Percentile
Percentile
Screening
Vision (Circle One) HOTV SNELLEN PICTURE Hearing (Circle One) Belltone Hear Kit
R ______ L ______ OU _______
R ________ L __________ OU _______
With glasses? Yes ___ No ___
Development (Circle One): SCREEN
DDST II PDQ NOT TESTED
Results: Untestable ______ Normal _________ Questionable ___________ Abnormal ______
Comments:___________________________________________________________________
Lab: Hgb/Hct (If indicated): Normal o Abnormalo; TB Skin Test (If Indicated): Normal o Abnormal o
Physical exam (0=normal, X=abnormal)
Head _____ Eyes ____ Ears _____ Nose ____ Mouth _____ Teeth _____ Throat _____
Breasts ____ Lungs ____ Heart _____ Abdomen ____ Genitalia ____ Extremities ____
Neurological ____ Skin/Nodes ____
Positive findings of any medical/dental conditions needing attention: ________________
_______________________________________________________________________
_______________________________________________________________________
Communicable Diseases: Tests (As Indicated)
o VDRL
Results:______________________________________________
o HIV/AIDS
Results:______________________________________________
o HEPATITIS B
Results:______________________________________________
o OTHER
Results:______________________________________________
Does child have signs or symptoms of any communicable disease(s) that would pose a
significant risk of transmission in a household setting? Yes ____ No ____ Unknown____
If yes, specify disease _________________________________________________________
Recommendations
Additional tests:_______________________________________________________________
Followup treatment:____________________________________________________________
Medications:__________________________________________________________________
Immunizations provided:________________________________________________________
Limitations on physical activity:___________________________________________________
Other:_______________________________________________________________________
____________________________________________________________________________
Examining physician (Signature)____________________________________Date__________
DSS-5244 (09/04) Family Support and Child Welfare Services
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