Fillable Printable Child & Adolescent Health Examination Form - New York

Child & Adolescent Health Examination Form - New York

TYPE OF EXAM: NAE Current NAE Prior Year(s)

Comments

REVIEWER:

Date

Reviewed:

DOHMH

ONLY

PROVIDER

I.D.

__ __ / ___ ___ / ___ ___

I.D. NUMBER

Health Care Provider Signature Date

__ __ / ___ ___ / ___ ___

Health Care Provider Name and Degree

(print) Provider License No. and State

Facility Name National Provider Identifier (NPI)

Address City State Zip

Telephone

( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___

Fax

( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___

Hep B __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Rotavirus __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

DTP/DTaP/DT __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Hib __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

PCV __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Polio __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

RECOMMENDATIONS  Full physical activity  Full diet

 Restrictions (

specify) ___________________________________________________________________________

Follow-up Needed  No  Yes, for _________________________ Appt. date: __ __ / ___ ___ / ___ ___

Referral(s):  None  Early Intervention  Special Education  Dental  Vision

 Other ________________________________________________________________________

ASSESSMENT  Well Child (V20.2)  Diagnoses/Problems

(list) ICD-9 Code

_____________________________________________________________ __ __ __ __ __

Health insurance  Yes

(including Medicaid)?  No

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

 Asthma

(check severity and attach MAF/Asthma Action Plan):  Intermittent  Mild Persistent  Moderate Persistent  Severe Persistent

If persistent, check all current medication(s):  Inhaled corticosteriod  Other controller  Quick relief med  Oral steroid  None

 Attention Deficit Hyperactivity Disorder  Orthopedic injury/disability

 Chronic or recurrent otitis media  Seizure disorder

 Congenital or acquired heart disorder  Speech, hearing, or visual impairment

 Developmental/learning problem  Tuberculosis

(latent infection or disease)

 Diabetes (attach MAF)  Other (specify) ___________________

Explain all checked items above or on addendum

Birth history

(age 0-6 yrs)

 Uncomplicated  Premature: ________ weeks gestation

 Complicated by _______________________________

Allergies  None  Epi pen prescribed

 Drugs

(list)

 Foods (list)

 Other (list)

STUDENT ID NUMBER

OSIS

CHILD & ADOLESCENT HEALTH EXAMINATION FORM

NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION

Please

Print Clearly

Press Hard

Child’s Last Name First Name Middle Name

Child’s Address

City/Borough State Zip Code

 Parent/Guardian Last Name First Name

 Foster Parent

School/Center/Camp Name

Sex  Female

 Male

Hispanic/Latino?

 Yes  No

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

 Native Hawaiian/Pacific Islander  Other ____________________________

PHYSICAL EXAMINATION

Height ____________________ cm ( ___ ___ %ile)

Weight ____________________ kg ( ___ ___ %ile)

BMI ____________________ kg/m

( ___ ___ %ile)

Head Circumference

(age ≤2 yrs) ______________ cm ( ___ ___ %ile)

Blood Pressure

(age ≥3 yrs) _________ / __________

DEVELOPMENTAL

(age 0-6 yrs)  Within normal limits

If delay suspected, specify below

 Cognitive

(e.g., play skills) ____________________________

 Communication/Language _________________________

 Social/Emotional __________________________________

 Adaptive/Self-Help ________________________________

 Motor ___________________________________________

SCREENING TESTS Date Done Results

Blood Lead Level (BLL)

__ __ / ___ ___ / ___ ___ _________ µg/dL

(required at age 1 yr and 2 yrs

and for those at risk)

__ __ / ___ ___ / ___ ___

_________ µg/dL

Lead Risk Assessment

 At risk

(do BLL)

(annually, age 6 mo-6 yrs)

__ __ / ___ ___ / ___ ___  Not at risk

Hearing

 Pure tone audiometry  Normal

 OAE

__ __ / ___ ___ / ___ ___  Abnormal

—— Head Start Only ——

Hemoglobin or __________ g/dL

Hematocrit

(age 9–12 mo)

__ __ / ___ ___ / ___ ___ __________ %

Date Done Results

Tuberculosis Only required for students entering intermediate/middle/junior or high school

who have not previously attended any NYC public or private school

PPD/Mantoux placed __ __ / ___ ___ / ___ ___

Induration ______mm

PPD/Mantoux read __ __ / ___ ___ / ___ ___  Neg  Pos

Interferon Test

__ __ / ___ ___ / ___ ___

 Neg  Pos

Chest x-ray  Nl  Not

(if PPD or Interferon positive)

__ __ / ___ ___ / ___ ___

 Abnl Indicated

Vision

__ __ / ___ ___ / ___ ___

Acuity Right ___ / ___

(required for new school entrants

Left ___ / ___

and children age 4–7 yrs)

 with glasses Strabismus  No  Yes

General Appearance:

Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl

 HEENT  Lymph nodes  Abdomen  Skin 

Psychosocial Development

 Dental  Lungs  Genitourinary  Neurological  Language

 Neck  Cardiovascular  Extremities  Back/spine  Behavioral

Date of Birth (Month/Day/Year )

__ __ / ___ ___ / ___ ___ ___ ___

Phone Numbers

Home _____________________

Cell ______________________

Work ______________________

TO BE COMPLETED BY PARENT OR GUARDIAN

TO BE COMPLETED BY HEALTH CARE PROVIDER If “yes” to any item, please explain (attach addendum, if needed)

CH-205 (5/08) Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian

Medications (attach MAF if in-school medication needed)

 None  Yes (list below)

Dietary Restrictions

 None  Yes

(list below)

Influenza __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

MMR __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Varicella __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Td __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Tdap __ __ / ___ ___ / ___ ___ Hep A __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Meningococcal __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

HPV __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Other, specify: ____________ __ __ / ___ ___ / ___ ___ ; _______________ __ __ / ___ ___ / ___ ___

IMMUNIZATIONS – DATES CIR Number

of Child

Describe abnormalities:

District __ __

Number __ __ __