Child Adolescent Health Form – Fill Out and Use This PDF

The Child Adolescent Health Examination Form is a comprehensive document created by the NYC Department of Health & Mental Hygiene and the Department of Education to gather essential health information about children and adolescents. It's designed to be filled out by parents or guardians and healthcare practitioners, covering everything from medical history, immunizations, developmental assessments, to physical exams. This form plays a pivotal role in ensuring the well-being of students within the education system. For the health and safety of your child, it is crucial to fill out this form accurately. Click the button below to begin the process.

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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.

Question	Answer
Form Name	Child Adolescent Health Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	ch 205 form, ch 205 health exam, child and adolescent health examination form nyc, ch205

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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

(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

Abnl

Nl Abnl

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

____ /____ /____

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

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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