Health Assessment Form For Compliance With K.s.a. 72-5214 Page 3
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3PHYSICAL EXAMINATION:
To be completed by health care provider approved to perform health assessments.
Height:
______________
Weight:
______________
Hgb or Hct: _____________
Pulse:
______________
Blood Pressure:
______________
Lead:
_____________
Urinalysis:
______________
Sickle Cell:
______________
Other:
_____________
Tuberculosis: ______________
Head Circumference: ______________
Code each item as follows:
Code
Description of Findings
0 = No significant findings
1 = significant findings
General appearance
Integument
Head – neck
EENT
Oral – dental
Thorax
Breasts
Cardiovascular
Abdomen
Musculoskeletal
Genitourinary
Neurological
SCREENING
1. Nutritional evaluation ( all ages-each screen) ( check if applicable).
Enrolled in WIC Receiving vitamin supplement with iron Without Iron Fluoride Supplement
Food intake review. Results:
Milk/milk products (breast fed/type of formula) _______________________________________
Fruit/vegetables _________________________________________________________________
Meat, beans, eggs _______________________________________________________________
Breads, cereals _________________________________________________________________
2. Development:
Type of screen ____________ Results: ________________________________
3. Speech:
Type of screen ____________ Results: ________________________________
4. Hearing:
Type of screen ____________ Results: ____________Date Last Screen:______
5. Vision:
Type of screen ____________ Results: ____________Date Last Screen:______
Significant assessment findings:
Anticipatory Guidance (circle those discussed)
1. Safety/poisons
8. Lifestyle
2. Nutrition
9. Development
Recommendations (include referrals):
3. Parenting
10. Behavior
4. Family planning
11. Sexuality
5. Discipline
12. Dental
Follow Up:
6. Immunizations
13. Other
7. Hygiene
Comments:
____________________________________________________________
Signature of physician or nurse approved to perform health assessments
____________________________
Date
Additional information may be attached.
Kansas Department of Health and Environment, Bureau for Children, Youth & Families. 12/92
Posted July 2000
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