Fillable Printable Universal Child Health Record - New Jersey
Fillable Printable Universal Child Health Record - New Jersey
Universal Child Health Record - New Jersey
UNIVERSAL
CHILD HEALTH RECORD
Endorsed by:American Academy of Pediatrics, New Jersey Chapter
New Jersey Academy of Family Physicians
New Jersey Department of Health
SECTION I - TO BE COMPLETED BY PARENT(S)
Child’s Name (Last)(First)
Gender
Male
Female
Date of Birth
//
Does Child Have Health Insurance?
Yes No
If Yes, Name of Child's Health Insurance Carrier
Parent/Guardian Name
Home Telephone Number
Work Telephone/Cell Phone Number
Parent/Guardian Name
Home Telephone Number
Work Telephone/Cell Phone Number
I give my consent for my child’s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form.
Signature/Date
This form may be released to WIC.
YesNo
SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDER
Date of Physical Examination:
Results of physical examination normal?
Yes
No
Weight (must be taken
within 30 days for WIC)
Height (must be taken
within 30 days for WIC)
Head Circumference
(if <2 Years)
Abnormalities Noted:
Blood Pressure
(if >3 Years)
IMMUNIZATIONS
Immunization Record Attached
Date Next Immunization Due:
MEDICAL CONDITIONS
Chronic Medical Conditions/Related Surgeries
•List medical conditions/ongoing surgical
concerns:
None
Special Care Plan
Attached
Comments
Medications/Treatments
•List medications/treatments:
None
Special Care Plan
Attached
Comments
Limitations to Physical Activity
•List limitations/special considerations:
None
Special Care Plan
Attached
Comments
Special Equipment Needs
•List items necessary for daily activities
None
Special Care Plan
Attached
Comments
Allergies/Sensitivities
•List allergies:
None
Special Care Plan
Attached
Comments
Special Diet/Vitamin & Mineral Supplements
•List dietary specifications:
None
Special Care Plan
Attached
Comments
Behavioral Issues/Mental Health Diagnosis
•List behavioral/mental health issues/concerns:
None
Special Care Plan
Attached
Comments
Emergency Plans
•List emergency plan that might be needed and
the sign/symptoms to watch for:
None
Special Care Plan
Attached
Comments
PREVENTIVE HEALTH SCREENINGS
Type ScreeningDate PerformedRecord ValueType ScreeningDate PerformedNote if Abnormal
Hgb/Hct
Hearing
Lead:
Capillary
Venous
Vision
TB (mm of Induration)
Dental
Other:
Developmental
Other:
Scoliosis
I have examined the above student and reviewed his/her health history. It is my opinion that he/she is medically cleared to
participate fully in all child care/school activities, including physical education and competitive contact sports, unless noted above.
Name of Health Care Provider (Print)
Signature/Date
Health Care Provider Stamp:
CH-14 JUL 12
Distribution: Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider
Instructions for Completing the Universal Child Health Record (CH-14)
Section 1 - Parent
Please have the parent/guardian complete the top section and
sign the consent for the child care provider/school nurse to
discuss any information on this formwith the health care
provider.
The WIC box needs to be checked only if this form is being
sent to the WIC office. WIC is a supplemental nutrition
program for Women, Infants and Children that provides
nutritious foods, nutrition counseling, health care referrals and
breast feeding support to income eligible families. For more
information about WIC in your area call 1-800-328-3838.
Section 2 - Health Care Provider
1.Please enter the date of the physical exam that is being
used to complete the form. Note significant abnormalities
especially if the child needs treatment for that abnormality
(e.g. creams for eczema; asthma medications for
wheezing etc.)
•
Weight - Please note pounds vs. kilograms. If the
form is being used for WIC, the weight must have
been taken within the last 30 days.
•
Height - Please note inches vs. centimeters. If the
form is being used for WIC, the height must have
been taken within the last 30 days.
•
Head Circumference - Only enter if the child is less
than 2 years.
•
Blood Pressure - Only enter if the child is 3 years
or older.
2.
Immunization - A copy of an immunization record may
be copied and attached. If you need a blank form on
which to enter the immunization dates, you can request a
supply of Personal Immunization Record (IMM-9) cards
from the New JerseyDepartment of Health, Vaccine
Preventable Diseases Program at 609-826-4860.
•
The Immunization record must be attached for the
form to be valid.
•“Date next immunization is due” is optional but helps
child care providers to assure that children in their
care are up-to-date with immunizations.
3.
Medical Conditions - Please list any ongoing medical
conditions that might impact the child's health and well
being in the child care or school setting.
a. Note any significant medical conditions or major
surgical history.
If thechild has a complex
medical condition, a special care plan should be
completed and attached for any of the medical
issue blocks that follow. A generic care plan
(CH-15) can be downloaded at
www.nj.gov/health/forms/ch-15.dot
or pdf. Hard
copies of the CH-15 can be requested from the
Division of Family Health Services at 609-292-5666.
b.
Medications
-
List anyongoing medications.
Include any medications given at home if they might
impact the child's health while in child care (seizure,
cardiac or asthma medications, etc.). Short-term
medications such as antibiotics do not need to be
listed on this form. Long-term antibiotics such as
antibiotics for urinary tract infections or sickle cell
prophylaxis should be included.
PRN Medications are medications given only as
needed and should have guidelines as to specific
factors that should trigger medication administration.
Please be specific about what over-the-counter
(OTC) medications you recommend, and include
information for the parent and child care provider as
to dosage, route, frequency, and possible side
effects. Many child care providers may require
separate permissions slips for prescription and OTC
medications.
c.
Limitations to physical activity - Please be as
specific as possible and include dates of limitation
as appropriate. Anylimitation to field trips should be
noted. Note anyspecial considerations such as
avoiding sun exposure or exposure to allergens.
Potential severe reaction to insect stings should be
noted. Special considerations such as back-only
sleeping for infants should be noted.
d.
Special Equipment
– Enter if the child wears
glasses, orthodontic devices, orthotics, or other
special equipment. Childrenwith complex
equipment needs should have a care plan.
e.
Allergies/Sensitivities -
Children with life-
threatening allergies should have a special care
plan. Severe allergic reactions to animals or foods
(wheezing etc.) should be noted. Pediatric asthma
action plans can be obtained from The Pediatric
Asthma Coalition of New Jersey at www.pacnj.org
or by phone at 908-687-9340.
f.
Special Diets - Any special diet and/or supplements
that are medically indicated should be included.
Exclusive breastfeeding should be noted.
g.
Behavioral/Mental Health issues – Please note
any significant behavioral problems or mental health
diagnoses such as autism, breath holding, or
ADHD.
h.
Emergency Plans - May require a special care plan
if interventions are complex. Be specific about
signs and symptoms to watch for. Use simple
language and avoid the use of complex medical
terms.
4.
Screening - This section is required for school, WIC,
Head Start, child care settings, and some other
programs. This section can provide valuable data for
public heath personnel to track children's health. Please
enter the date that the test was performed. Note if the
test was abnormal or place an "N" if it was normal.
•For lead screening state if the blood sample was
capillaryor venous and the value of the test
performed.
•
For PPD enter millimeters of induration, and the
date listed should be the date read. If a chest x-ray
was done, record results.
•
Scoliosis screenings are done bienniallyin the
public schools beginning at age 10.
This formmaybe used for clearance for sports or
physical education. As such, please check the box above
the signature line and make any appropriate notations in
the Limitation to Physical Activities block.
5.Please sign and date the form with the date the form was
completed (note the date of the exam, if different)
•
Print the health care provider's name.
•
Stamp with health care site's name, address and
phone number.
