Ch-2J, Child Health Conference: Health Assessment
|New Jersey Department of Health |DATE: | |
|CHILD HEALTH CONFERENCE – HEALTH ASSESSMENT | | |
|CHILDHOOD: 3 Years | | |
|Child’s Name |Date of Birth |
| | |
|Allergies |Illnesses/Injuries/Problems/Concerns |Current Medications |
| | | |
|rn: |apn/pa/md/do: |
|subjectIVE |SUBJECTIVE |
|Y |N | | Review of Family History |
| | | |__________________________________________ |
| | | |__________________________________________ |
| | | |__________________________________________ |
| | | |__________________________________________ |
| | | |__________________________________________ |
| | |My child eats a variety of foods | |
| | |My child knows his or her own name, age and sex | |
| | |My family understands my child’s speech | |
| | |My child can jump off a step with both feet | |
| | |My child is dry during the night most of the time | |
| | |I have concerns about my child’s hearing/vision | |
|Diet: ___________________________________________ | |
| | Review of Systems |
| |__________________________________________ |
| |__________________________________________ |
| |__________________________________________ |
| |__________________________________________ |
| |__________________________________________ |
| |Vitamin Supplements WIC Referral | |
| |Fluoride Supplements Dental Referral | |
| |Lead Risk Assessment (verbal) Hgb/Hct | |
| |Review Immunization Record Audiogram Referral | |
| |TB Test (if risks factor present) | |
| |Cholesterol Screening (high risk children) | |
|Elimination: ________________________________ | |
|Sleep: ____________________________________ | |
|Other: ____________________________________ | |
| |OBJECTIVE: PHYSICAL |
| | |N |A | |N |A |
| |General Appearance | | |Lungs | | |
| |Skin | | |Chest | | |
|Health Education/Anticipatory Guidance: |Head | | |Cardiovascular/Pulses | | |
|(CHECK ALL COMPLETED) |Eyes | | |Abdomen | | |
| |Nutrition | |Toilet Training |Ears | | |Genitalia | | |
| |Safety (general) | |Passive Smoke |Nose | | |Spine | | |
| |Car Seat or Booster Seat | |Friendship/Siblings |Oropharynx/Teeth | | |Extremities | | |
| |Development Benchmarks | |Discipline/Limits |Dental Structure/Tongue | | |Neurological | | |
| |Limit TV | |Oral Health Care |Mental Health | | | | | |
| |Lead Poisoning Prevention | |Supervision | | | | |
| |Child Care Issues | | |ASSESSMENT (Problem List) |
| |Other: ____________________________________________ |__________________________________________ |
| | |__________________________________________ |
| | |
|OBJECTIVE: SCREENING | |
|weight kg/lb |height cm/in |blood pressure: |PLAN |
|percentile: |percentile: | |__________________________________________ |
| | | |__________________________________________ |
| | | |__________________________________________ |
| | | | |
| |N |A | | |
|Hearing | | |________________________ | |
|Vision | | |________________________ | |
|Development | | |________________________ |REFERRALS |
| | | | |__________________________________________ |
| | | | |__________________________________________ |
|Behavior | | |________________________ | |
|Social/Emotional | | |________________________ | |
|Gross Motor | | |________________________ | |
|Fine Motor | | |________________________ |APN/PA/MD/DO SIGNATURE: |
| | |
|RN ASSESSMENT: |RN PLAN: |REFERRALS: |
| | | |
| | | |
|RN SIGNATURE: | |
| | |
|NEXT VISIT: 4 YEARS OF AGE |IMMUNIZATIONS: Given Up to date |
CH-2J / JUL 12 (Adapted from EPSDT form: DHS DMAHS/OQT/NJ HMOs) Additional notes on reverse side(
ADDITIONAL NOTES
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