ChiLD & ADOLEsCEnT hEALTh ExAMinATiOn FORM Please

NYC ID (OSIS)
NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION Print Clearly

TO BE COMPLETED BY ThE PAREnT OR GUARDiAn

Child’s Last Name First Name Middle Name Sex M Female Date of Birth (Month/Day/Year )
UMAR RANA F M Male 12/19/2005
___ ___ / ___ ___ / ___ ___ ___ ___
Child’s Address Hispanic/Latino? Race (Check ALL that apply) M American Indian M Asian M Black M White
2034 Cropsey Avenue M Yes M No M Native Hawaiian/Pacific Islander M Other _____________________________
City/Borough State Zip Code School/Center/Camp Name District __ __ Phone Numbers
BROOKLYN NY 11214 Number __ __ __ Home (347) 713-1806
___________________

Health insurance M Yes M Parent/Guardian Last Name First Name Email Cell _________
(including Medicaid)? M No M Foster Parent
Work
TO BE COMPLETED BY ThE hEALTh CARE PRACTiTiOnER
Birth history (age 0-6 yrs) Does the child/adolescent have a past or present medical history of the following?
M Uncomplicated M Premature: ______ weeks gestation M Asthma (check severity and attach MAF): M Intermittent M Mild Persistent M Moderate Persistent M Severe Persistent
If persistent, check all current medication(s): M Quick Relief Medication M Inhaled Corticosteroid M Oral Steroid M Other Controller M None
M Complicated by _________________________________ Asthma Control Status M Well-controlled M Poorly Controlled or Not Controlled
M Anaphylaxis M Seizure disorder Medications (attach MAF if in-school medication needed)
Allergies M None M Epi pen prescribed M Behavioral/mental health disorder M Speech, hearing, or visual impairment M None M Yes (list below)
M Congenital or acquired heart disorder M Tuberculosis (latent infection or disease)
M Drugs (list) __________________________________________ M Developmental/learning problem M Hospitalization
M Diabetes (attach MAF) M Surgery
M Foods (list) __________________________________________ M Orthopedic injury/disability M Other (specify)
M Other (list) __________________________________________ Explain all checked items above. M Addendum attached.

Attach MAF if in-school medications needed

PHYSICAL EXAM Date of Exam: ___ /___ /___ General Appearance:
M Physical Exam WNL
Height _____________ cm ( ___ ___ %ile)
Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl
Weight _____________ kg ( ___ ___ %ile) M M Psychosocial Development M M HEENT M M Lymph nodes M M Abdomen M M Skin
BMI _____________ kg/m2 ( ___ ___ %ile) M M Language M M Dental M M Lungs M M Genitourinary M M Neurological
M M Behavioral M M Neck M M Cardiovascular M M Extremities M M Back/spine
Head Circumference (age ≤2 yrs) _______ cm ( ___ ___ %ile)
Describe abnormalities:
Blood Pressure (age ≥3 yrs) _________ / _________
DEVELOPMENTAL (age 0-6 yrs) Nutrition Hearing Date Done Results
Validated Screening Tool Used? Date Screened < 1 year M Breastfed M Formula M Both < 4 years: gross hearing ____/____/____ MNl MAbnl MReferred
≥ 1 year M Well-balanced M Needs guidance M Counseled M Referred
M Yes M No ____/____/____ OAE ____/____/____ MNl MAbnl MReferred
Dietary Restrictions M None M Yes (list below)
Screening Results: M WNL ≥ 4 yrs: pure tone audiometry ____/____/____ MNl MAbnl MReferred
M Delay or Concern Suspected/Confirmed (specify area(s) below): Vision Date Done Results
M Cognitive/Problem Solving M Adaptive/Self-Help SCREENING TESTS Date Done Results
<3 years: Vision appears: ____/____/____
M Nl M Abnl
M Communication/Language M Gross Motor/Fine Motor Blood Lead Level (BLL) ____ /____
02/18/13 /____ _________
3 µg/dL Acuity (required for new entrants Right _____ /_____
M Social-Emotional or M Other Area of Concern: (required at age 1 yr and 2 and children age 3-7 years) ____/____/____ Left _____ /_____
Personal-Social __________________________ yrs and for those at risk) ____ /____ /____ 3_________ µg/dL
02/22/12 M Unable to test
Describe Suspected Delay or Concern: M At risk (do BLL) Screened with Glasses? M Yes M No
Lead Risk Assessment
(annually, age 6 mo-6 yrs) ____ /____ /____ Strabismus? M Yes M No
M Not at risk Dental
—— Child Care Only —— Visible Tooth Decay M Yes M No
Hemoglobin or __________ g/dL Urgent need for dental referral (pain, swelling, infection) M Yes M No
____ /____ /____ Dental Visit within the past 12 months M Yes M No
Child Receives EI/CPSE/CSE services M Yes M No Hematocrit __________ %
CIR Number Physician Confirmed History of Varicella Infection Report only positive immunity:
636007263
IMMUNIZATIONS – DATES IgG Titers Date
02/04/06
DTP/DTaP/DT ____ /____ /____ 03/04/06
____ /____ /____ 04/04/06
____ /____ /____ 06/02/09
____ /____ /____ 01/07/10
____ /____ /____ ____ /____ /____ Tdap 09/09/17
____ /____ /____ ____ /____ /____ Hepatitis B ____ /____ /____
Td ____ /____ /____ ____ /____ /____ ____ /____ /____ ____ /____ /____ ____ /____ /____ MMR 12/26/06
____ /____ /____ 06/02/09
____ /____ /____ ____ /____ /____ Measles ____ /____ /____
02/04/06
Polio ____ /____ /____ 04/03/06
____ /____ /____ 06/02/09
____ /____ /____ 11/19/14
____ /____ /____ ____ /____ /____ Varicella 06/02/09
____ /____ /____ 10/10/09
____ /____ /____ ____ /____ /____ Mumps ____ /____ /____
02/04/06
Hep B ____ /____ /____ 03/04/06
____ /____ /____ 06/02/09
____ /____ /____ ____ /____ /____ ____ /____ /____ Mening ACWY 09/09/17
____ /____ /____ ____ /____ /____ ____ /____ /____ Rubella ____ /____ /____
02/04/06
Hib ____ /____ /____ 03/04/06
____ /____ /____ 04/04/06
____ /____ /____ 06/02/09
____ /____ /____ ____ /____ /____ Hep A 06/27/09
____ /____ /____ 03/16/10
____ /____ /____ ____ /____ /____ Varicella ____ /____ /____
06/27/09
PCV ____ /____ /____ ____ /____ /____ ____ /____ /____ ____ /____ /____ ____ /____ /____ Rotavirus ____ /____ /____ ____ /____ /____ ____ /____ /____ Polio 1 ____ /____ /____
08/29/13
Influenza ____ /____ /____ 11/19/14
____ /____ /____ 10/14/15
____ /____ /____ 10/12/17
____ /____ /____ 10/26/21
____ /____ /____ Mening B ____ /____ /____ ____ /____ /____ ____ /____ /____ Polio 2 ____ /____ /____
HPV ____ /____ /____ ____ /____ /____ ____ /____ /____ ____ /____ /____ ____ /____ /____ Other __ ____ /____ /____ _ ____ /____ /____ Polio 3 ____ /____ /____
ASSESSMENT Well Child (Z00.129) Diagnoses/Problems (list) ICD-10 Code RECOMMENDATIONS Full physical activity
M Restrictions (specify) ____________________________________________________________________________
Follow-up Needed M No M Yes, for ___________________________ Appt. date: __ __ / ___ ___ / ___ ___
Referral(s): M None M Early Intervention M IEP M Dental M Vision
M Other ____________________________________________________________________________
Health Care Practitioner Signature Date Form Completed DOHMH PRACTITIONER
_____ /_____ /_____ ONLY I.D.
Health Care Practitioner Name and Degree (print) Practitioner License No. and State TYPE OF EXAM: NAE Current NAE Prior Year(s)
Comments:
Facility Name National Provider Identifier (NPI)
Family health care pllc Date Reviewed: I.D. NUMBER
Address City State Zip ______ / ______ / ______
2116 BATH AVENUE Brooklyn NY 11214 REVIEWER:
Telephone Fax Email
FORM ID#

CH205_Health_Exam_2016_June_2016.indd