ChiLD & ADOLEsCEnThEALT h ExAMinATiOn FORM Print Clearly

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? M Yes M No School/Center/Camp Name

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

Race (Check all that apply) M American Indian M Asian M Black M White

M Native Hawaiian/Pacific Islander M Other _____________________________

District ____ Phone Numbers Number ____ __ Home ___________________

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

M Uncomplicated M Premature: ______ weeks gestation

M Asthma (check severity and attach MAF): M Intermittent

M Mild Persistent

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

M Moderate Persistent

M Severe Persistent

M Oral Steroid M Other Controller M None

M Complicated by _________________________________ Asthma Control Status

M Well-controlled

M Poorly Controlled or Not Controlled

AllergiesM NoneM Epi pen prescribed

M Anaphylaxis M Behavioral/mental health disorder

M Congenital or acquired heart disorder MDrugs(list)__________________________________________ M Developmental/learning problem

MFoods(list)__________________________________________

M Diabetes (attach MAF) M Orthopedic injury/disability

MOther(list)__________________________________________ Explain all checked items above.

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

M Addendum attached.

Medications (attach MAF if in-school medication needed)

M None

M Yes (list below)

Attach MAF in in-school medications needed

PHYSICAL EXAM

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

Height _____________ cm Weight _____________ kg

( ___ ___ %ile) Nl Abnl

M Physical Exam WNL Nl Abnl

( ___ ___ %ile) M M Psychosocial Development M M HEENT

BMI _____________ kg/m2

( ___ ___ %ile) M M Language

M M Behavioral Head Circumference (age 2 yrs) _______ cm ( ___ ___ %ile) Describe abnormalities:

M M Dental M M Neck

Nl Abnl M M Lymph nodes M M Lungs M M Cardiovascular

Nl Abnl M M Abdomen M M Genitourinary M M Extremities

Nl Abnl M M Skin M M Neurological M M Back/spine

Blood Pressure (age 3 yrs) _________ / _________

Developmental (age 0-6 yrs)

Nutrition

Validated Screening Tool Used?

Date Screened < 1 year M Breastfed M Formula M Both

M Yes M No Screening Results: M WNL

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

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

M Cognitive/Problem Solving

M Adaptive/Self-Help

SCREENING TESTS

Date Done

Results

M Communication/Language

MSocial-Emotional or Personal-Social

M Gross Motor/Fine Motor M 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

Hearing

Date Done

Results

< 4 years: gross hearing

____/____/____ MNl MAbnl MReferred

OAE

____/____/____ MNl MAbnl MReferred

4 yrs: pure tone audiometry ____/____/____ MNl MAbnl MReferred

Vision

Date Done

Results

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