Universal Health Certificate - District of Columbia

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Part 1: Child’s Personal Information Parent/Guardian: Please complete Part 1 clearly and completely & sign Part 5 below.
Child’s Last Name: Child’s First & Middle Name: Date of Birth:
Gender:
M
F
Race/Ethnicity:
White Non Hispanic
Black Non Hispanic
Hispanic
Asian or Pacific Islander
Other______________
Parent or Guardian Name: Telephone:
Home
Cell
Work
Home Address:
Ward:
Emergency Contact Person: Emergency Number:
Home
Cell
Work
City/State (if other than D.C.)
Zip code:
School or Child Care Facility:
Medicaid
Private Insurance
None
Other ________________________________
Primary Care Provider (PCP):
Part 2: Child’s Health History, Examination & Recommendation s Health Provider: Form must be fully completed.
DATE OF HEALTH EXAM: WT LBS
KG
HT IN
CM
BP:
(>3 yrs)
NML
ABNL
Body Mass Index
(>2 yrs)
(BMI)___________
%______________
HGB / HCT
(Required for Head Start)
Vision Screening
Right 20/____ Left 20/____
Glasses
Referred
Hearing Screening
Pass________ Fail________ Referred
HEALTH CONCERNS: REFERRED or TREATED HEALTH CONCERNS: REFERRED or TREATED
Asthma
NO
YES
Referred Under Rx
Language/Speech
NONE
YES Referred Under Rx
Seizure
NO
YES
Referred Under Rx
Development/
Behavioral
NONE
YES Referred Under Rx
Diabetes
NO
YES
Referred Under Rx
Other____________
NONE
YES Referred Under Rx
ANNUAL DENTIST VISIT: (Age 3 and older): Has the child seen a Dentist/Dental Provider within the last year? YES NO Referred
A. Significant health history, conditions, communicable illness, or restrictions that may affect school, child care, sports, or camp.
NONE YES, please detail:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
B. Significant food/medication/environmental allergies that may require emergency medical car e at school, child care, camp , or
sports activity.
NONE YES, please detail: _________ __________________________________________________________________________
_____________________________________________________________________________________________________________
C. Long-term medications, over-the-counter-drugs (OTC) or special care requirements.
NONE YES, please detail (
For any medications or treatment required during school hours, a Physician’s Medicati on Authorization Order
should be submitted with this form)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Part 3: Tuberculosis & Lead Exp osure Risk Assessment & Testing:
TB RISK ASSESSMENTS
HIGHÆ
LOW
Tuberculin Skin Test
(TST) DATE:
NEGATIVE
POSITIVE
If TST Positive
CXR NEGATIVE
CXR POSITIVE
TREATED
Health Provider: PO SITIVE TS T
should be referred to PCP f or
evaluation. For questions, call T.B.
Control: 202-698-4040
LEAD EXPOSURE RISKS
YE SÆ
NO
LEAD TEST DATE:
RESULT:
Health Provider: ALL lead levels must be reported to DC Childhood Lead
Poisoning Prevention Program:
Fax: 202-481-3770
Part 4: Require d Provider Certification and Signature
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__________________________________________________________________
Print Name
MD/NP Signature Date
Address Phone Fax
Part 5: Require d Parental/Guardian Signatures. (Release of Health Information)
I give permission to the signing health examiner/facility to share the health information on this form with my child’ s school, child care, camp, or appropriate DC Government Agency.
Print Name Signature Date
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Universal Health Certificate - District of Columbia PDF

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