Form Chd 02 - Head Start Well Child Exam
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1Head Start/Early Head Start
Health Services Coordinator
126 Woodlake Drive SE
Rochester, MN 55904
HEAD START WELL CHILD EXAM
507.424.1532 ~ Fax 507.287.2411
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______month WC
3 year
4 year
5 year
Child's Name: __________________________________________ Date of Birth: _____________________ Sex: ______
Physician’s Name:_______________________________________ Date of Exam: _______________________________
Name of Clinic: _________________________________________ Medical Record #: ____________________________
Please note: These items are Federally Mandated for Head Start children in accordance with the MN EPSDT schedule of age-related standards
**Please provide previous applicable lab results**
Head Circumference _________cm/inches.
Height ______cm/inches.
Weight ______kg/lbs. Blood Pressure_____/_____
Hearing Right Ear _______DB □Normal □Abnormal □Question Validity/Retest □Refer
Left Ear __________DB □Normal □Abnormal □Question Validity/Retest □Refer
Vision Right Eye____/____ □Normal □Refer to Eye Clinic □Question Validity/Retest
Left Eye____/____ □Normal □Refer to Eye Clinic □Question Validity/Retest
HGB* Results_________ Date ________ Lead* Results_______ Date_________ TB Questionnaire___ High Risk Yes or No
(*Please provide HCT/HGB & Lead results from the child’s 9, 12 or 24 month Well Child Exam* Past lab results accepted)
Please attach a copy of child’s immunization record.
Immunizations current? Yes or No
Area
N/AB
Comments
Area
N/AB
Comments
1. Head
10. Spine
2. Face
11. Cardiovascular
3. Neck
12. Abdomen
4. Eyes
13. Genitalia
5. Ears
14. Extremities
6. Nose
15. Joints
7. Mouth
16. Muscle Tone
8. Throat
17. Skin
9. Chest
18. Neurological
APGAR SCORES: 1 minute: _________________ 5 minutes: _____________________
1.
Does child have any allergies? (food, drug, insect, other) No Yes If yes, please circle type and give recommendations:
___________________________________________________________________________________________________________
2.
Is child developing appropriately for his/her age? No Yes
If no, what modifications are needed: _____________________________
3.
Is a special diet necessary? No Yes
Please identify restrictions: _____________________________________________________
4.
Is there a condition which may result in an emergency? No Yes Please specify: __________________________________________
5.
Please indicate any notable health problems: _______________________________________________________________________
6.
If noted, any restrictions or recommendations: ______________________________________________________________________ .
7.
Referrals:____________________________________________________________________________________________________
Printed Health Provider Name______________________________________ Provider Signature__________________________________
Parent/Guardian Signature____________________________________________________ Date___________________________________
)
I authorize this information to be mailed or faxed from my medical facility to Head Start. 126 Woodlake Drive SE, Rochester MN 55904 or faxed to: (507-287-2411
Rev. 4.15
Return to Health Services Coordinator
Form_CHD_02
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Parent category: Medical