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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