Da 7625-1 - Army Child And Youth Services Health Screening Tool Page 2

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d. Child has experienced unconsciousness or seizures associated with asthma attacks
No
Yes (explain)
e. Child required an urgent visit to emergency room or clinic for acute asthma within the last 12 months
No
Yes (indicate number of visits in the past year)
f. Child has been hospitalized for asthma related condition in the past six months
No
Yes (explain)
3. Attention Deficit Disorder (ADD)
No
Yes
a. ADD with hyperactivity
No
Yes
b. Is not well controlled with medication
No
Yes (not well controlled)
c. Behavioral/conduct concerns
No
Yes (explain)
4. Autism
No
Yes
5. Behavioral/conduct concerns (for example, oppositional defiant disorder, anxiety disorder, school phobias)
No
Yes (explain)
6. Blindness/visual problems
No
Yes (explain)
7. Diabetes
No
Yes (explain)
8. Emotional problems that require care by a psychiatrist, psychologist or social worker
No
Yes (explain)
9. Epilepsy
No
Yes (explain)
10. Hearing problems
No
Yes (explain)
11. Heart problems
No
Yes (explain)
12. Kidney problems
No
Yes (explain)
13. Speech/language delay
No
Yes (explain)
14. Physical disability
No
Yes (explain)
15. Dietary restrictions
No
Yes (explain)
Page 2 of 3
DA FORM 7625-1, NOV 2006
APD V1.00

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