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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