Form Ch205 - Childand Adolescent Health Examination Form printable pdf download

ChiLD & ADOLEsCEnT hEALTh ExAMinATiOn FORM

Please

NYC ID (OSIS)

Print Clearly

NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION

TO BE COMPLETED BY ThE PAREnT OR GUARDiAn

Child’s Last Name

First Name

Middle Name

Sex M Female

Date of Birth

)

(Month/Day/Year

M Male

___ ___ / ___ ___ / ___ ___ ___ ___

Child’s Address

Hispanic/Latino?

Race

M American Indian M Asian M Black M White

(Check ALL that apply)

M Yes M No

M Native Hawaiian/Pacific Islander M Other _____________________________

City/Borough

State

Zip Code

School/Center/Camp Name

District __ __

Phone Numbers

Number __ __ __

Home ___________________

Cell _________

Health insurance

M Parent/Guardian Last Name

First Name

M Yes

(including Medicaid)? M No

M Foster Parent

Work

TO BE COMPLETED BY ThE hEALTh CARE PRACTiTiOnER

Birth history

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

(age 0-6 yrs)

M Asthma

(check severity and attach MAF):

Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent

M Uncomplicated

M Premature: ______ weeks gestation

If persistent, check all current medication(s):

Quick Relief Medication

Inhaled Corticosteroid

Oral Steroid

Other Controller

None

M Complicated by _________________________________

Asthma Control Status

Well-controlled

Poorly Controlled or Not Controlled

M Anaphylaxis

M Seizure disorder

Medications

(attach MAF if in-school medication needed)

Allergies M None M Epi pen prescribed

M Behavioral/mental health disorder

M Speech, hearing, or visual impairment

M None

M Yes

(list below)

M Congenital or acquired heart disorder

M Tuberculosis

(latent infection or disease)

M Drugs

(list) __________________________________________

M Developmental/learning problem

M Hospitalization

M Diabetes

M Surgery

(attach MAF)

M Foods

(list) __________________________________________

M Orthopedic injury/disability

M Other (specify)

Explain all checked items above.

M Addendum attached.

M Other

(list) __________________________________________

Attach MAF if in-school medications needed

PHYSICAL EXAM

Date of Exam: ___ /___ /___

General Appearance:

M Physical Exam WNL

Height

_____________ cm

( ___ ___ %ile)

Nl Abnl

Weight

_____________ kg

( ___ ___ %ile)

M M Psychosocial Development M M HEENT

M M Lymph nodes

M M Abdomen

M M Skin

M M Language

M M Dental

M M Lungs

M M Genitourinary

M M Neurological

BMI

_____________ kg/m

( ___ ___ %ile)

M M Behavioral

M M Neck

M M Cardiovascular

M M Extremities

M M Back/spine

Head Circumference

_______ cm ( ___ ___ %ile)

(age ≤2 yrs)

Describe abnormalities:

Blood Pressure

_________ / _________

(age ≥3 yrs)

Nutrition

DEVELOPMENTAL

Hearing

Date Done

Results

(age 0-6 yrs)

< 1 year M Breastfed M Formula M Both

Validated Screening Tool Used?

Date Screened

< 4 years: gross hearing

____/____/____ M

Abnl

Referred

≥ 1 year M Well-balanced M Needs guidance M Counseled M Referred

M Yes M No

____/____/____

OAE

____/____/____ M

Abnl

Referred

Dietary Restrictions M None M Yes (list below)

Screening Results: M WNL

≥ 4 yrs: pure tone audiometry

____/____/____ M

Abnl

Referred

M Delay or Concern Suspected/Confirmed (specify area(s) below):

Vision

Date Done

Results

SCREENING TESTS

Date Done

Results

Cognitive/Problem Solving

Adaptive/Self-Help

<3 years: Vision appears:

____/____/____

Abnl

_________ µg/dL

_____ /_____

Communication/Language

Gross Motor/Fine Motor

Blood Lead Level (BLL)

Right

____ /____ /____

Acuity (required for new entrants

_____ /_____

____/____/____

(required at age 1 yr and 2

Left

Social-Emotional or

Other Area of Concern:

and children age 3-7 years)

____ /____ /____

yrs and for those at risk)

_________ µg/dL

Personal-Social

M Unable to test

__________________________

Describe Suspected Delay or Concern:

M At risk (do BLL)

Screened with Glasses?

M Yes

M No

Lead Risk Assessment

____ /____ /____

Strabismus?

M Yes

M No

(annually, age 6 mo-6 yrs)

M Not at risk

Dental

—— Child Care Only ——

Visible Tooth Decay

M Yes

M No

__________ g/dL

Urgent need for dental referral (pain, swelling, infection)

M Yes

M No

Hemoglobin or

____ /____ /____

Dental Visit within the past 12 months

M Yes

M No

Hematocrit

__________ %

Child Receives EI/CPSE/CSE services

M Yes M No

CIR Number

Physician Confirmed History of Varicella Infection

Report only positive immunity:

IMMUNIZATIONS – DATES

IgG Titers Date

DTP/DTaP/DT ____ /____ /____

____ /____ /____ ____ /____ /____

Tdap

Hepatitis B

____ /____ /____

MMR

Measles

____ /____ /____

Polio

Varicella

Mumps

____ /____ /____

Hep B

Mening ACWY

Rubella

____ /____ /____

Hib

Hep A

Varicella

____ /____ /____

PCV

Rotavirus

Polio 1

____ /____ /____

Influenza

Mening B

Polio 2

____ /____ /____

HPV

Other

Polio 3

____ /____ /____

ASSESSMENT

Well Child (Z00.129)

Diagnoses/Problems

ICD-10 Code

RECOMMENDATIONS

Full physical activity

(list)

M Restrictions (

specify) ____________________________________________________________________________

Follow-up Needed M No M Yes, for ___________________________ Appt. date:

__ __ / ___ ___ / ___ ___

Referral(s):

M None

M Early Intervention

M IEP

M Dental

M Vision

M Other ____________________________________________________________________________

Health Care Practitioner Signature

Date Form Completed

DOHMH

PRACTITIONER

ONLY

_____ /_____ /_____

I.D.

Health Care Practitioner Name and Degree

Practitioner License No. and State

TYPE OF EXAM:

(print)

NAE Current

NAE Prior Year(s)

Comments:

Facility Name

National Provider Identifier (NPI)

I.D. NUMBER

Date Reviewed:

Address

City

State

Zip

______ / ______ / ______

REVIEWER:

Telephone

Fax

FORM ID#

CH205_Health_Exam_2016_June_2016.indd

Form Ch205 - Childand Adolescent Health Examination Form

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