UNIVERSAL Endorsed by: American Academy of Pediatrics, New Jersey Chapter

New Jersey Academy of Family Physicians

CHILD HEALTH RECORD New Jersey Department of Health

SECTION I - TO BE COMPLETED BY PARENT(S)

Child’s Name (Last) (First) Gender Date of Birth

Fatoni Irfan Male 02 /May / 2016

Does Child Have Health Insurance? If Yes, Name of Child's Health Insurance Carrier
Yes
BPJS

Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number

Uswatun Khasanah - 081278809876

Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number

Dawam - 09876579879

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.

Yes

07 August 2021

SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDER

Date of Physical Examination: 07 August 2021 Results of physical examination normal? Yes

Abnormalities Noted: Weight (must be taken 20 kg

within 30 days for WIC)

Height (must be taken 123 cm

within 30 days for WIC)

Head Circumference 45 cm
(if <2 Years)

Blood Pressure 105/70

(if >3 Years)

IMMUNIZATIONS Immunization Record Attached

Date Next Immunization Due:

MEDICAL CONDITIONS

Chronic Medical Conditions/Related Surgeries • List None -

medical conditions/ongoing surgical concerns: Special Care Plan
Attached

Medications/Treatments None -
• List medications/treatments: Special Care Plan
Attached

Limitations to Physical Activity None -

• List limitations/special considerations: Special Care Plan
Attached

Special Equipment Needs None -

• List items necessary for daily activities Special Care Plan
Attached

Allergies/Sensitivities None -
• List allergies: Special Care Plan
Attached

Special Diet/Vitamin & Mineral Supplements • List None -

dietary specifications:
 Special Care Plan
Attached

Behavioral Issues/Mental Health Diagnosis • List None -

behavioral/mental health issues/concerns: Special Care Plan
Attached

Emergency Plans None -

• List emergency plan that might be needed and the Special Care Plan
sign/symptoms to watch for: Attached

PREVENTIVE HEALTH SCREENINGS

Type Screening Date Performed Record Value Type Screening Date Performed Note if Abnormal

Hgb/Hct Hearing 07-08-2021

Lead: Capillary Venous Vision 07-08-2021

TB (mm of Induration) Dental 07-08-2021

Other: Developmental 07-08-2021

Other: Scoliosis 07-08-2021

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) Health

Care
Provide
r
Stamp:

Signature/Date

07 August 2021

CH-14 JUL 12 Distribution: Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider
Instructions for Completing the Universal Child •Health
Section 1 - Parent Record
Height - Please (CH-14)
note inches vs. centimeters. If the form is
Please have the parent/guardian complete the top section being used for WIC, the height must have been taken
and sign the consent for the child care provider/school within the last 30 days.
nurse to discuss any information on this form with the • Head Circumference - Only enter if the child is less than 2
health care provider. years.
The WIC box needs to be checked only if this form is being • Blood Pressure - Only enter if the child is 3 years or older.
sent to the WIC office. WIC is a supplemental nutrition 2. Immunization - A copy of an immunization record may
program for Women, Infants and Children that provides be copied and attached. If you need a blank form on which
nutritious foods, nutrition counseling, health care referrals to enter the immunization dates, you can request a supply
and breast feeding support to income eligible families. For of Personal Immunization Record (IMM-9) cards from the
more information about WIC in your area call 1-800-328- New Jersey Department of Health, Vaccine Preventable
3838. Diseases Program at 609-826-4860.
Section 2 - Health Care Provider • The Immunization record must be attached for the form to
1. Please enter the date of the physical exam that is being be valid.
used to complete the form. Note significant abnormalities • “Date next immunization is due” is optional but helps child
especially if the child needs treatment for that abnormality care providers to assure that children in their care are up-
(e.g. creams for eczema; asthma medications for wheezing to-date with immunizations.
etc.) 3. Medical Conditions - Please list any ongoing medical
• Weight - Please note pounds vs. kilograms. If the form is conditions that might impact the child's health and well
being used for WIC, the weight must have been taken being in the child care or school setting.
within the last 30 days. a. Note any significant medical conditions or major surgical
history. If the child 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 noted. Pediatric asthma action plans can be obtained from
plan (CH-15) can be downloaded at The Pediatric Asthma Coalition of New Jersey at
www.nj.gov/health/forms/ch-15.dot or pdf. Hard copies of www.pacnj.org or by phone at 908-687-9340.
the CH-15 can be requested from the Division of Family f. Special Diets - Any special diet and/or supplements that
Health Services at 609-292-5666. are medically indicated should be included. Exclusive
b. Medications - List any ongoing medications. Include any breastfeeding should be noted.
medications given at home if they might impact the child's g. Behavioral/Mental Health issues – Please note any
health while in child care (seizure, cardiac or asthma significant behavioral problems or mental health diagnoses
medications, etc.). Short-term medications such as such as autism, breath holding, or ADHD.
antibiotics do not need to be listed on this form. Long-term h. Emergency Plans - May require a special care plan if
antibiotics such as antibiotics for urinary tract infections or interventions are complex. Be specific about signs and
sickle cell prophylaxis should be included. symptoms to watch for. Use simple language and avoid the
PRN Medications are medications given only as needed use of complex medical terms.
and should have guidelines as to specific factors that 4. Screening - This section is required for school, WIC,
should trigger medication administration. Head Start, child care settings, and some other programs.
Please be specific about what over-the-counter (OTC) This section can provide valuable data for public heath
medications you recommend, and include information for personnel to track children's health. Please enter the date
the parent and child care provider as to dosage, route, that the test was performed. Note if the test was abnormal
frequency, and possible side effects. Many child care or place an "N" if it was normal.
providers may require separate permissions slips for • For lead screening state if the blood sample was capillary
prescription and OTC medications. or venous and the value of the test performed.
c. Limitations to physical activity - Please be as specific as • For PPD enter millimeters of induration, and the date
possible and include dates of limitation as appropriate. Any listed should be the date read. If a chest x-ray was done,
limitation to field trips should be noted. Note any special record results.
considerations such as avoiding sun exposure or exposure • Scoliosis screenings are done biennially in the public
to allergens. Potential severe reaction to insect stings schools beginning at age 10.
should be noted. Special considerations such as back-only This form may be used for clearance for sports or physical
sleeping for infants should be noted. education. As such, please check the box above the
d. Special Equipment – Enter if the child wears glasses, signature line and make any appropriate notations in the
orthodontic devices, orthotics, or other special equipment. Limitation to Physical Activities block.
Children with complex equipment needs should have a 5. Please sign and date the form with the date the form
care plan. was completed (note the date of the exam, if different) •
e. Allergies/Sensitivities - Children with life threatening Print the health care provider's name.
allergies should have a special care plan. Severe allergic • Stamp with health care site's name, address and phone
reactions to animals or foods (wheezing etc.) should be number.
CH-14 (Instructions) JUL 12

Example 2
 PRINT SAVE AS RESET
Mail or Fax to:
MGH Release of
Information 121 Inner
Belt Road, Room 240
Somerville, MA 02143-
4453
Phone: 617 726 2361
AUTHORIZATION FOR RELEASE OF FAX: 617 726 3661
PROTECTED OR PRIVILEGED HEALTH For copies of radiology images
INFORMATION or films, contact 617 726 1798 /
Fax 617-726-0264

http://www.massgeneral.org/imaging/about/
order_images_films.aspx

A. PATIENT INFORMATION

PATIENT NAME: PATIENT DATE OF BIRTH: PATIENT MEDICAL RECORD # 00-06-21

PATIENT ADDRESS:STREET: APT. #:

CITY: STATE: ZIP CODE:

TELEPHONE CONTACT #:DAY: ( )EVENING: ( )

B. PERMISSION TO SHARE: I give my permission to share my protected health information.

From: To: PATIENT
Name:
Name:
Address:
Address:

Telephone Number: Telephone Number:

Fax Number:

Send by: Purpose (check the appropriate box)

□ Mail □ Medical Care ✓ □ Other (please specify)*

□ Insurance*
□ Electronically (secure email)✓
□ Legal Matter*
Email Address: □ Personal*
□ School * Copying fees may apply
C. INFORMATION TO BE RELEASED (Please check all that apply, and specify dates):

□ Medical Record Abstract/dates □ Radiation Reports/dates

(e.g. History &
Physical, Operative Report, Consults, Test □ Radiology Reports/dates
Reports, Discharge Summary)
□ Photographs/dates (costs may apply)
□ Clinic Visit Notes/dates
□ Billing Records/dates
□ Discharge Summary/dates
□ Other (please specify below and include dates)
□ Lab Reports/dates

□ Operative Reports/dates

□ Pathology Reports/dates

AUTHORIZATION FOR RELEASE OF

PROTECTED OR PRIVILEGED HEALTH
INFORMATION

D. Please check YES to indicate if you give permission to release the following information if
present in your record:
□ Yes HIV test results (PATIENT AUTHORIZATION REQUIRED FOR EACH RELEASE REQUEST.)

SPECIFY DATES 13 October

□ Yes Genetic Screening test results (SPECIFY TYPE OF TEST)
□ Yes Alcohol and Drug Abuse Records Protected by Federal Confidentiality Rules 42 CFR Part 2
(FEDERAL RULES PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION
UNLESS FURTHER DISCLOSURE IS EXPRESSLY PERMITTED BY WRITTEN CONSENT
OF THE PERSON TO WHOM IT PERTAINS OR AS OTHERWISE PERMITTED BY 42 CFR
PART 2.) This consent may be revoked upon oral or written request.
□ Yes Other(s): Please List
□ Yes Details of Mental Health Diagnosis and/or Treatment provided by a Psychiatrist, Psychologist, Mental
Health Clinical Nurse Specialist, or Licensed Mental Health Clinician (LMHC) (I understand that
my permission may not be required to release my mental health records for payment
purposes)
□ Yes Confidential Communications with a Licensed Social Worker
□ Yes Details of Domestic Violence Victims’ Counseling
□ Yes Details of Sexual Assault Counseling
 E. I understand and agree that:
• Partners HealthCare System (PHS) cannot control how the recipient uses or shares the information, and
that laws protecting its confidentiality at PHS may or may not protect this information once it has been
released to the recipient
• This authorization is voluntary
• My treatment, payment, health plan enrollment, or eligibility for benefits will not be affected if I do
not sign this form
• I may cancel this authorization at any time by submitting a written request to the Department or
Office where I originally submitted it, except:
o if PHS has already relied upon it (for example, once information is released, it will not be
retrieved)
o if I signed this authorization as a condition of obtaining insurance, other laws may provide the
insurer with a right to contest a claim under the policy or the policy itself
• This authorization will automatically expire 6 months from the date signed unless otherwise
specified:
• My questions about this authorization form have been answered

Patient’s Signature: ➢ Date:

➢ Print Name:
When patient is a minor, or is not competent to give consent, the signature of a parent, guardian, or other legal
representative is required.

Signature of Legal Representative: Date:

Print Name: Relationship of representative to

patient:

For Internal Use Only

Information Released/Reviewed By: Date

Clinic/Office:

Pick-up Identification:
License State ID Passport OtherPhotoID

Name : Muhammad Irfan Fatoni

NIM : P07137121004
Prodi : D3 RMIK