West Virginia Child Health Assessment - Wvu Medicine

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West Virginia Department of Health and Human Resources
CHILD HEALTH ASSESSMENT
Child’s Name ___________________________________________
Parent/Guardian _________________________________________
DOB ____/____/________ Home Phone _____________________
Address _______________________________________________
Child Care Facility/School _________________________________
______________________________________________________
Child Care Facility/School Phone ___________________________
W ork Phone ____________________________________________
Note: A copy of the Health Check exam report attached to a copy of the child’s immunization record may be substituted for this form.
Health history and medical information pertinent to routine child care and emergencies:
Date Of Exam ____/____/______
Allergies to food or medicine:
Length/Height
Weight
Head Circumference
Blood Pressure
___________in/cm
%ile __________
___________in/cm
%ile __________
___________in/cm
%ile __________
___________in/cm
%ile __________
Physical Examination
Normal
Abnormal/Comments
Head/Ears/Eyes/Nose/Throat
Teeth
Cardiorespiratory
Abdomen/GI
Genitalia/Breasts
Extremeties/Joints/Back/Chest
Skin/Lymph Nodes
Neurologic/Tone
Developmental (e.g. ddst)
Birth to 1 Month
2 Month
4 Month
6 Month
12-18 Month
4-6 Yrs
Immunizations
DTP/DTaP
Polio
HIB
HEP B
MMR
Varicella
Other (PCV7)
Note: Ages and number of boosters may vary when immunizations start at older ages.
Screening Tests
Date
Normal
Abnormal/Comments
(If completed)
Lead
Anemia (HGB/HCT)
Urinalysis (UA)
Tuberculosis (TB)
Hearing
Vision
Note: Age appropriate health services and immunizations must follow the schedule recommended by AAP
D ate of Last D entist’s Exam
Health Problems or Special Needs
Recommended Treatment/Medications/Special Care (Attach additional sheets if necessary)
MD
Medical Care Provider
DO
Address
PA
CRNP
________________________________________________________________________________
Phone
Date
Signature of Physician or CRNP
EC E-C C -3
12/04

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