Child Adolescent Health Form PDF Details

Focused on ensuring the comprehensive well-being of children and adolescents, the Child & Adolescent Health Examination Form is an essential tool designed by the New York City Department of Health & Mental Hygiene in conjunction with the Department of Education. It serves a crucial role in documenting a wide range of health-related information, including birth history, past and present medical history, allergies, medications, and physical examination results. The form solicits detailed information from the parent or guardian about the child’s demographics, health insurance status, and school or center they attend. It also requires completion by a healthcare practitioner who assesses various aspects of the child's health, such as development and nutrition, hearing and vision screenings, immunizations, and offers recommendations for follow-ups or further assessment if needed. This meticulous compilation of health data is pivotal not only for tracking the child's health status over time but also for identifying any areas requiring immediate attention or ongoing monitoring, thus underpinning the importance of this form in safeguarding children’s and adolescents' health and ensuring they receive the necessary care and interventions.

QuestionAnswer
Form NameChild Adolescent Health Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesch 205 form, ch 205 health exam, child and adolescent health examination form nyc, ch205

Form Preview Example

CHILD & ADOLESCENT HEALTH EXAMINATION FORM

NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION

Please Print Clearly

NYC ID (OSIS)

TO BE COMPLETED BY THE PARENT OR GUARDIAN

Child’s Last Name

First Name

Middle Name

Sex ☐ Female

Male

Date of Birth (Month/Day/Year )

___ ___ / ___ ___ / ___ ___ ___ ___

Child’s Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hispanic/Latino?

Race (Check ALL that apply)

 

☐ American Indian ☐ Asian

☐ Black

☐ White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Yes

 

☐ No

☐ Native Hawaiian/Pacific Islander

☐ Other _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/Borough

 

 

 

 

 

 

State

 

 

Zip Code

 

 

 

School/Center/Camp Name

 

 

 

 

 

 

 

 

 

District

__ __

Phone Numbers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number __ __ __

Home ___________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell

_________

 

 

 

 

Health insurance

☐ Yes

Parent/Guardian Last Name

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(including Medicaid)? ☐ No

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Uncomplicated ☐ Premature: ______ weeks gestation

☐ Asthma (check severity and attach MAF):

Intermittent

 

 

 

Mild Persistent

 

 

 

Moderate Persistent

 

Severe Persistent

 

 

 

 

If persistent, check all current medication(s):

Quick Relief Medication

Inhaled Corticosteroid

 

Oral Steroid Other Controller

None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Complicated by

_________________________________

 

Asthma Control Status

 

 

 

Well-controlled

 

 

 

Poorly Controlled or Not Controlled

 

 

 

 

 

 

 

 

 

 

 

 

 

Allergies ☐ None ☐ Epi pen prescribed

 

 

 

 

 

 

 

☐ Anaphylaxis

 

 

 

 

☐ Seizure disorder

 

 

 

 

 

 

 

Medications (attach MAF if in-school medication needed)

 

 

 

 

 

 

 

 

 

☐ Behavioral/mental health disorder

☐ Speech, hearing, or visual impairment

 

 

☐ None

 

☐ Yes (list below)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Congenital or acquired heart disorder

☐ Tuberculosis

(latent infection or disease)

 

 

 

 

 

 

 

 

 

☐ Drugs (list) __________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Developmental/learning problem

☐ Hospitalization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Foods (list) __________________________________________

☐ Diabetes (attach MAF)

 

 

 

☐ Surgery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Orthopedic injury/disability

☐ Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Other (list) __________________________________________

Explain all checked items above.

Addendum attached.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach MAF if in-school medications needed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL EXAM

 

Date of Exam: ___ /___ /___

General Appearance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height

_____________ cm

 

 

( ___ ___ %ile)

 

 

 

 

 

 

 

 

 

☐ Physical Exam WNL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nl

Abnl

 

 

 

Nl Abnl

 

 

 

 

 

 

Nl Abnl

 

 

 

 

 

Nl

Abnl

 

 

Nl Abnl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight

_____________ kg

 

 

( ___ ___ %ile)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ ☐ Psychosocial Development

☐ ☐ HEENT

 

 

 

☐ ☐ Lymph nodes

 

 

 

☐ ☐ Abdomen

 

☐ ☐ Skin

 

 

 

 

 

 

BMI

_____________ kg/m2

 

( ___ ___ %ile)

☐ ☐ Language

 

 

 

☐ ☐ Dental

 

 

 

☐ ☐ Lungs

 

 

 

☐ ☐ Genitourinary

☐ ☐ Neurological

 

 

 

Head Circumference (age 2 yrs)

_______ cm ( ___ ___ %ile)

☐ ☐ Behavioral

 

 

 

☐ ☐ Neck

 

 

 

☐ ☐ Cardiovascular

 

☐ ☐ Extremities

 

☐ ☐ Back/spine

 

 

 

 

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 ☐ Breastfed

☐ Formula ☐ Both

 

 

 

 

 

 

 

< 4 years: gross hearing

 

____/____/____

Nl

 

Abnl

Referred

☐ Yes

☐ No

 

 

____/____/____

1 year Well-balanced ☐ Needs guidance ☐ Counseled ☐ Referred

 

OAE

 

 

 

 

 

 

 

 

 

____/____/____

Nl

 

Abnl

Referred

Screening Results: ☐ WNL

 

 

 

 

 

 

 

 

Dietary Restrictions

☐ None ☐ Yes (list below)

 

 

 

 

 

 

 

≥ 4 yrs: pure tone audiometry

____/____/____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nl

 

Abnl

Referred

☐ Delay or Concern Suspected/Confirmed (specify area(s) below):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision

 

 

 

 

 

 

 

Date Done

 

 

 

 

 

 

Results

 

 

Cognitive/Problem Solving

Adaptive/Self-Help

SCREENING TESTS

 

 

Date Done

 

 

 

 

Results

 

 

<3 years: Vision appears:

 

____/____/____

Nl

Abnl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Communication/Language

Gross Motor/Fine Motor

Blood Lead Level (BLL)

 

____ /____ /____

 

_________ µg/dL

 

Acuity (required for new entrants

 

 

 

 

 

Right _____ /_____

Social-Emotional or

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)

 

 

_________ µg/dL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Unable to test

Describe Suspected Delay or Concern:

 

 

 

 

 

 

 

Lead Risk Assessment

 

____ /____ /____

 

☐ At risk (do BLL)

Screened with Glasses?

 

 

 

 

 

 

☐ Yes

☐ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Strabismus?

 

 

 

 

 

 

 

 

 

 

 

 

☐ Yes

☐ No

 

 

 

 

 

 

 

 

 

 

 

 

(annually, age 6 mo-6 yrs)

 

 

☐ Not at risk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

—— Child Care Only ——

 

__________ g/dL

 

Visible Tooth Decay

 

 

 

 

 

 

 

 

☐ Yes

☐ No

 

 

 

 

 

 

 

 

 

 

 

 

Hemoglobin or

 

 

____ /____ /____

 

 

Urgent need for dental referral (pain, swelling, infection)

 

☐ Yes

☐ No

Child Receives EI/CPSE/CSE services

 

 

☐ Yes ☐ No

Hematocrit

 

 

 

__________ %

 

Dental Visit within the past 12 months

 

 

 

 

 

 

☐ Yes

☐ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CIR Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician Confirmed History of Varicella Infection

 

 

 

 

 

 

 

 

 

 

 

Report only positive immunity:

IMMUNIZATIONS – DATES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IgG Titers

 

Date

 

 

 

DTP/DTaP/DT

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

 

 

 

 

Tdap

____ /____ /____

 

 

____ /____ /____

 

Hepatitis B

____ /____ /____

 

 

Td

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

 

 

 

MMR

____ /____ /____

____ /____ /____

 

 

____ /____ /____

 

 

Measles

____ /____ /____

 

Polio

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

 

 

Varicella

____ /____ /____

____ /____ /____

 

 

____ /____ /____

 

 

Mumps

____ /____ /____

 

Hep B

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

Mening ACWY

____ /____ /____

____ /____ /____

 

 

____ /____ /____

 

 

Rubella

____ /____ /____

 

 

Hib

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

 

 

Hep A

____ /____ /____

____ /____ /____

 

 

____ /____ /____

 

 

Varicella

____ /____ /____

 

 

PCV

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

 

Rotavirus

____ /____ /____

____ /____ /____

 

 

____ /____ /____

 

 

 

Polio 1

____ /____ /____

 

Influenza

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

 

Mening B

____ /____ /____

____ /____ /____

 

 

____ /____ /____

 

 

 

Polio 2

____ /____ /____

 

 

HPV

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

____ /____ /____

Other

 

 

 

__

 

____ /____ /____

 

_

 

 

 

 

____ /____ /____

 

 

 

Polio 3

____ /____ /____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSESSMENT

Well Child (Z00.129)

 

 

 

Diagnoses/Problems (list)

ICD-10 Code

RECOMMENDATIONS

Full physical activity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Restrictions (specify) ____________________________________________________________________________

Follow-up Needed ☐ No

☐ Yes, for ___________________________

Appt. date: __ __ / ___ ___ / ___ ___

Referral(s): ☐ None

☐ Early Intervention

☐ IEP

☐ Dental

☐ Vision

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Reviewed:

 

 

i.D. NUMBER

Address

City

 

 

State

Zip

______ / ______ / ______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

reviewer:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone

Fax

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM ID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CH205_Health_Exam_2016_June_2016.indd

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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part 1 to completing nyc physical exam form

Fill in the Blood Pressure age yrs, Date Screened, M Yes M No Screening Results M WNL, M AdaptiveSelfHelp M Gross, Nutrition year M Breastfed M, SCREENING TESTS, Date Done, Results, Blood Lead Level BLL required at, gdL, Hearing, Date Done, Results, years gross hearing, and MNl MAbnl MReferred field using the data requested by the application.

part 2 to finishing nyc physical exam form

You can be asked to write down the data to let the application fill out the segment Health Care Practitioner Signature, M Other, Date Form Completed, DOHMH ONLY, PRACTITIONER ID, Health Care Practitioner Name and, Practitioner License No and State, Facility Name, Address, Telephone, National Provider Identifier NPI, City, State, Zip, and Fax.

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