Nj Form Child PDF Details

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QuestionAnswer
Form NameNj Form Child
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnew jersey form health, nj universal health form, universal health form nj, universal child health form

Form Preview Example

UNIVERSAL

CHILD HEALTH RECORD

Endorsed by: American Academy of Pediatrics, New Jersey Chapter New Jersey Academy of Family Physicians

New Jersey Department of Health

SECTION I ­ TO BE COMPLETED BY PARENT(S)

Child’s Name (Last)

(First)

Gender

Male

Female

Date of Birth

/ /

 

Does Child Have Health Insurance?

If Yes, Name of Child's Health Insurance Carrier

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Name

 

 

 

 

 

Home Telephone Number

 

Work Telephone/Cell Phone Number

 

 

 

 

 

 

 

 

 

(

)

­

 

 

 

 

(

 

)

­

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Name

 

 

 

 

 

Home Telephone Number

 

Work Telephone/Cell Phone Number

 

 

 

 

 

 

 

 

 

(

)

­

 

 

 

 

(

 

)

­

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II ­ TO BE COMPLETED BY HEALTH CARE PROVIDER

 

 

 

Date of Physical Examination:

 

 

 

 

Results of physical examination normal?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abnormalities Noted:

 

 

 

 

 

 

 

 

 

 

 

Weight (must be taken

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

within 30 days for WIC)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height (must be taken

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

within 30 days for WIC)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Head Circumference

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(if <2 Years)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blood Pressure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(if >3 Years)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMMUNIZATIONS

 

 

Immunization Record Attached

 

 

 

 

 

 

 

 

 

Date Next Immunization Due:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL CONDITIONS

 

 

 

 

 

Chronic Medical Conditions/Related Surgeries

 

None

 

Comments

 

 

 

 

 

•

List medical conditions/ongoing surgical

 

 

Special Care Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

concerns:

 

 

 

 

Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

Medications/Treatments

 

 

 

 

None

 

Comments

 

 

 

 

 

 

 

 

 

Special Care Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

•

List medications/treatments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Limitations to Physical Activity

 

 

None

 

Comments

 

 

 

 

 

 

 

Special Care Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

•

List limitations/special considerations:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Equipment Needs

 

 

 

 

None

 

Comments

 

 

 

 

 

 

 

 

 

Special Care Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

•

List items necessary for daily activities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Allergies/Sensitivities

 

 

 

 

None

 

Comments

 

 

 

 

 

 

 

 

 

Special Care Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

•

List allergies:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Diet/Vitamin & Mineral Supplements

 

 

None

 

Comments

 

 

 

 

 

 

 

Special Care Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

•

List dietary specifications:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Behavioral Issues/Mental Health Diagnosis

 

 

None

 

Comments

 

 

 

 

 

 

 

Special Care Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

• List behavioral/mental health issues/concerns:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Plans

 

 

 

 

None

 

Comments

 

 

 

 

 

• List emergency plan that might be needed and

 

Special Care Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lead:

Capillary

Venous

 

 

 

 

 

 

 

 

Vision

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TB (mm of Induration)

 

 

 

 

 

 

 

 

 

Dental

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

Developmental

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

Scoliosis

 

 

 

 

 

 

 

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 Provider Stamp:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature/Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CH­14

OCT 17

Distribution: Original­Child Care Provider Copy­Parent/Guardian Copy­Health Care Provider

 

 

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Best ways to fill in nj universal child health record step 1

2. Your next stage is to complete these fields: MEDICAL CONDITIONS Comments, concerns, MedicationsTreatments, List medicationstreatments, Limitations to Physical Activity, List limitationsspecial, Special Equipment Needs, List items necessary for daily, AllergiesSensitivities, List allergies, Special DietVitamin Mineral, List dietary specifications, Behavioral IssuesMental Health, List behavioralmental health, and Emergency Plans.

Step number 2 in submitting nj universal child health record

A lot of people frequently make some mistakes while completing Behavioral IssuesMental Health in this section. Ensure you review what you enter right here.

3. The next part is normally simple - fill out all the fields in Name of Health Care Provider Print, Health Care Provider Stamp, SignatureDate, CH OCT, and Distribution OriginalChild Care to complete the current step.

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