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
2
( ___ ___ %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 __ __ __
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