Wisconsin Initial Refugee Health Assessment
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6DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
s. 252.04, Wis. Stats.
F-42017 (Rev. 09/13)
(608) 267-3733
FAX: (608) 266-0049
Page 1 of 6
WISCONSIN INITIAL REFUGEE HEALTH ASSESSMENT
Client information is confidential under Wisconsin Statute 146.82(1)
Please read instructions before completing this form.
General Information (Review overseas medical documentation)
Admission Status:
Asylee
Amerasian
Cuban/Haitian
Victim of Trafficking
Refugee
Immigrant
Name - First, Middle, Last (include name suffix i.e. Jr., Sr. etc.)
Alien or Visa Registration No.
Race
Date of Birth (mm/dd/yyyy)
Sex
Male
Female
U.S. Arrival Date
Country of Origin
Refugee Camp/Port of Entry
Class B TB status: Class:
B1
B2
B3
Class B, Other Specify:
No
No
Yes (requires follow-up soon after arrival)
Yes (requires follow-up soon after arrival)
Resettlement agency (“VOLAG”) and contact person/telephone no.
Family File number
How will clinic be reimbursed for this screening?
Medical Assistance
Health Screening Contract
Other
Date of First Clinic Visit for Screening:
Interpreter Needed?
Yes
No
If yes, which language?
Literate in own language?
Yes
No
Vital Signs
Height (in.):
Weight (lbs):
Head Circum (inches) infants
BMI:
and children:
BP:
Pulse:
Resp:
Temp:
Significant information from physical exam:
Wheel chair/ mobility device
Dialysis
Oxygen
Other:
Vision and Hearing Screening (check all that apply)
Vision Screening:
Not done
Wears glasses/contacts
Hearing Screening:
OD 20/
OS 20/
Normal
Abnormal
Uses aids
Not done
Oral Screening (check all that apply)
Urgent Referral
Early Referral
Preventive Referral
Oral Screening not done
Cavities/caries present but no pain
Apparent fillings present
Cavities/caries present and pain present
Periodontal disease signs present
Apparent dental sealants
Pain present in teeth and/or jaw with or
(redness, swelling and/or sores on gums,
No apparent problems or dental
without biting/chewing
and/or hard build-up on teeth)
disease
Open sores present in mouth or gums
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