Ch-2p, Child Health Conference: Health Assessment, 9 Years
|New Jersey Department of Health |DATE: | |
|CHILD HEALTH CONFERENCE – HEALTH ASSESSMENT | | |
|CHILDHOOD: 9 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 breakfast every day | |
| | |My child is doing well in school | |
| | |My child has one or more close friends | |
| | |My child seems rested when he/she awakens | |
| | |My child handles stress, anger and frustration appropriately | |
| | |My child gets some physical activity every day | |
|Diet: ___________________________________________ | Review of Systems |
| |__________________________________________ |
| |__________________________________________ |
| |__________________________________________ |
| |__________________________________________ |
| |__________________________________________ |
| |Vitamin Supplements Menarche | |
| |Fluoride Supplements Hgb/Hct | |
| |Review Immunization Record Dental Referral | |
| |TB Test (if high risk 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 | |Oral Health Care |Ears | | |Genitalia | | |
| |Development | |Parenting Issues |Nose | | |Spine | | |
| |Regular Physical Activities | |Child Care Issues |Oropharynx/Teeth | | |Extremities | | |
| |Seat Belt | |Adequate Sleep |Dental Structure/Tongue | | |Neurological | | |
| |Safety (general) | |Helmets |Mental Health | | | | | |
| |Passive Smoke | |School Issues | | | | |
| |Limit TV | |Firearm Safety |ASSESSMENT (Problem List) |
| | | | |__________________________________________ |
| | | | |__________________________________________ |
| |Menarche | |Drug, Alcohol | |
| |Sexual Behavior | | | |
| | |
|OBJECTIVE: SCREENING |PLAN |
| |__________________________________________ |
| |__________________________________________ |
| |__________________________________________ |
|weight kg/lb |height cm/in |blood pressure: | |
|percentile: |percentile: | | |
| | | | |
| | | | |
| |N |A | | |
|Hearing | | |________________________ |REFERRALS |
| | | | |__________________________________________ |
| | | | |__________________________________________ |
|Vision | | |________________________ | |
|Development | | |________________________ | |
|Behavior | | |________________________ | |
|Social/Emotional | | |________________________ |APN/PA/MD/DO SIGNATURE: |
| | |
|RN ASSESSMENT: |RN PLAN: |REFERRALS: |
| | | |
| | | |
|RN SIGNATURE: | |
| | |
|NEXT VISIT: 10-12 YEARS OF AGE |IMMUNIZATIONS: Given Up to date |
CH-2P / JUL 12 (Adapted from EPSDT form: DHS DMAHS/OQT/NJ HMOs) Additional notes on reverse side(
ADDITIONAL NOTES
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