CHILD & ADOLESCENT HEALTH EXAMINATION FORM Print Clearly

[Pages:1]CHILD & ADOLESCENT HEALTH EXAMINATION FORM

Please

NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE -- DEPARTMENT OF EDUCATION

Print Clearly

NYC ID (OSIS)

TO BE COMPLETED BY THE PARENT OR GUARDIAN

Child's Last Name

First Name

Child's Address

City/Borough

State

Zip Code

Middle Name

Hispanic/Latino? Yes No School/Center/Camp Name

Sex Female Date of Birth (Month/Day/Year ) Male ___ ___ / ___ ___ / ___ ___ ___ ___

Race (Check ALL that apply) American Indian Asian Black White

Native Hawaiian/Pacific Islander Other _____________________________

District __ __ Phone Numbers Number __ __ __ Home ___________________

Health insurance Yes Parent/Guardian Last Name (including Medicaid)? No Foster Parent

First Name

Email

Cell _________ Work

TO BE COMPLETED BY THE HEALTH CARE PRACTITIONER

Birth history (age 0-6 yrs)

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

Uncomplicated Premature: ______ weeks gestation

Asthma (check severity and attach MAF): Intermittent

Mild Persistent

If persistent, check all current medication(s): Quick Relief Medication Inhaled Corticosteroid

Moderate Persistent

Severe Persistent

Oral Steroid Other Controller None

Complicated by _________________________________ Asthma Control Status

Well-controlled

Poorly Controlled or Not Controlled

Allergies None Epi pen prescribed

Anaphylaxis Behavioral/mental health disorder

Drugs (list) __________________________________________

Congenital or acquired heart disorder Developmental/learning problem

Foods (list) __________________________________________

Diabetes (attach MAF) Orthopedic injury/disability

Other (list) __________________________________________ Explain all checked items above.

Seizure disorder Speech, hearing, or visual impairment Tuberculosis (latent infection or disease) Hospitalization Surgery Other (specify) Addendum attached.

Medications (attach MAF if in-school medication needed)

None

Yes (list below)

Attach MAF in in-school medications needed

PHYSICAL EXAM

Date of Exam: ___ /___ /___ General Appearance:

Height _____________ cm Weight _____________ kg

( ___ ___ %ile)

Physical Exam WNL

Nl Abnl

Nl Abnl

( ___ ___ %ile) Psychosocial Development HEENT

BMI _____________ kg/m2

( ___ ___ %ile) Language

Head Circumference (age d2 yrs) _______ cm ( ___ ___ %ile)

Behavioral Describe abnormalities:

Dental Neck

Nl Abnl Lymph nodes Lungs Cardiovascular

Nl Abnl Abdomen Genitourinary Extremities

Nl Abnl Skin Neurological Back/spine

Blood Pressure (age t3 yrs) _________ / _________

DEVELOPMENTAL (age 0-6 yrs)

Nutrition

Hearing

Date Done

Results

Validated Screening Tool Used?

Date Screened < 1 year Breastfed Formula Both

Yes No Screening Results: WNL

____/____/____

t 1 year Well-balanced Needs guidance Counseled Referred Dietary Restrictions None Yes (list below)

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

Cognitive/Problem Solving

Adaptive/Self-Help

SCREENING TESTS

Date Done

Results

Communication/Language

Social-Emotional or Personal-Social

Gross Motor/Fine Motor

Other Area of Concern: __________________________

Blood Lead Level (BLL) (required at age 1 yr and 2 yrs and for those at risk)

____ /____ /____ _________ ?g/dL ____ /____ /____ _________ ?g/dL

< 4 years: gross hearing

____/____/____ Nl Abnl Referred

OAE

____/____/____ Nl Abnl Referred

t 4 yrs: pure tone audiometry ____/____/____ Nl Abnl Referred

Vision

Date Done

Results

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