Form Pps-2k - North Carolina Kindergarten Health Assessment Report Page 2
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1
2Personal Data
PPS-2K Rev. 1/11
Child's Birthdate:
/
20 _____ (mm/dd/yyyy)
Race:
1 Other Non-White
5 Chinese
9 Other Asian
Sex:
1 Male
2 Female
2 White
6 Japanese
10 Unknown
3 Black
7 Hawaiian
County of Residence:
4 American Indian
8 Filipino
Zip Code:
Hispanic or Latino Origin:
1 Yes
2 No
School your child will be attending:
Child has:
3 No Insurance
1 Medicaid
Place where your child
gets regular health care:
2 Private Insurance/HMO
4 Other:
4 Private Doctor/HMO
1 Health Department
Doctor/Practice Name:
5 Other
2 Hospital Clinic
6 No regular place
3 Community Health Center
Dentist Name:
Date of Health Assessment:
/
/
The health assessment must be conducted by a physician licensed to practice medicine, a physician's assistant as defined in General Statute
90-18, a certified nurse practitioner, or a public health nurse meeting the state standards for Health Check Services.
Immunizations - Attach a copy of the immunization record.
Pertinent Illnesses, Risks or Developmental Problems:
(Please check all that apply)
Orthopedic Conditions
Allergy
Diabetes
Prematurity (<32 wks. EGA)
Anemia
At-Risk for Anemia
Emotional/Behavioral
Asthma
Encopresis
Seizures/Convulsions
Attention/Learning
Enuresis (Daytime)
Trait
Sickle Cell Anemia
Bleeding Disorder
Genetic Disorders
Speech/Language
Cancer/Leukemia
Heart Conditions
Tuberculosis
At-Risk for TB
Cerebral Palsy
Vision Disorders
Hearing Disorders
Cystic Fibrosis
Kidney Disorders
Other:
Dental Conditions
Lead (Hx of >10 mcg/dL)
At-Risk
None
Test done
Screening Results
Obesity
Concern Identified Referred to Specialist
Within Normal
Screening Tool(s) Used:
Developmental Domains:
1
2
3
Comments:
Emotional/Social
4 PSC
1 PEDS
Problem Solving
2 ASQ
5 ASQ-SE
Language/Communication
Fine Motor Skills
Gross Motor Skills
Hearing
1000 Hz
2000 Hz
4000 Hz
Screening Tool Used:
1 Pass
2 Scheduled for re-screen due to middle ear fluid.
1 OAE
Right
Re-screen appt. in
weeks.
2 Audiometry
3 Referral to audiologist/ENT (check if yes)
Left
4 Child has previously diagnosed hearing loss. Screening
Indicate Pass (P) or Refer (R) in each box. Refer means any failure at
is not necessary.
any frequency in either ear at >20dB.
Please remember that vision screening is not a substitute
1 Pass ( Acuity, Stereopsis, & Symptoms)
for a comprehensive eye examination.
Refer if worse than 20/40
2 Referral to eye doctor (check if YES)
Left
Stereopsis
Right
in either or both eyes, a two line difference between eyes,
Pass
Fail
unable to test, failed stereopsis, or signs of disease.
/
/
Far:
Test Used:
20
20
Acuity
3 Child has a diagnosed vision condition and has had an eye
Was test performed with corrective lenses?
yes
no
exam in the last 12 months. Screening is not necessary.
Physical Examination
Weight:
lbs.
Height:
ft.
in.
Normal
Abnormal
1
2
Body Mass Index (BMI) - for age:
HEENT
1 Underweight (< 5%ile)
Dental/Oral
2 Healthy Weight (5%ile to < 85%ile)
Lungs
3 Overweight (85%ile to < 95%ile)
Cardiac
Abdomen
4 Obese ( > 95%ile)
Neurological
Blood Pressure:
/
Back/Extremities
1 Within Normal Range
Genital
th
2 > 90
Percentile (
%ile)
Skin
Comments:
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Parent category: Medical