CHILD & ADOLESCENT HEALTH EXAMINATION Please

Print Clearly NYC ID (OSIS)

FORM
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 )
M Male
/ /
Child’s Address Hispanic/Latino? Race (Check ALL that apply) M American Indian M Asian M Black M White
M Yes M No M Native Hawaiian/Pacific Islander M Other
City/Borough
State Zip Code School/Center/Camp Name District Phone Numbers
Number Home

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

Allergies M None M Epi pen M Anaphylaxis M Seizure disorder Medications (attach MAF if in-school medication needed)
prescribed M Behavioral/mental health disorder M Speech, hearing, or visual M None M Yes (list below)
impairment
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 in in-school medications needed

PHYSICAL EXAM Date of Exam: / / General Appearance:
Height cm ( %ile) M Physical Exam WNL
Weight kg ( %ile) Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl
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
Head Circumference (age 2 yrs) cm ( %ile) M M Behavioral M M Neck M M Cardiovascular M M Extremities M M 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 M Breastfed M Formula M < 4 years: gross / / MNl MAbnl MReferred
Both hearing
M Yes M No  1 year M Well-balanced M Needs guidance M Counseled M
/ /
Referred OAE / / MNl MAbnl MReferred
Screening Results: M WNL Dietary Restrictions M None M Yes (list below)  4 yrs: pure tone / / MNl MAbnl MReferred
audiometry
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 Blood Lead Level / / µg/dL Acuity (required for new entrants Right /
Motor (BLL)
M Social-Emotional or M Other Area of (required at age 1 yr and children age 3-7 / / Left /
Concern: and 2 years)
Personal-Social yrs and for those at risk) / / µg/dL M Unable to test
M At risk (do Screened with Glasses? M Yes M No
Describe Suspected Delay or Concern: Lead Risk Assessment
BLL) Strabismus? M Yes M No
(annually, age 6 mo-6
yrs) / / Dental
M Not at risk
—— Child Care Only —— Visible Tooth Decay M Yes M No
Hemoglobin or g/dL Urgent need for dental referral (pain, swelling, M Yes M No
infection)
Child Receives EI/CPSE/CSE services M Yes M No / / Dental Visit within the past 12 M Yes M No
Hematocrit %
months
Physician Confirmed History of Varicella Report only positive
CIR Number Infection immunity:
Date
IMMUNIZATIONS – DATES IgG Titers
/ /
DTP/DTaP/DT / / / / / / / / / / / /
Td / / / / / / / / / / MMR / / Tdap // // // // Hepatitis
Measles B / /
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
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 Date Form Completed DOHMH PRACTITIONER
Signature
 / / ONLY I.D.
Health Care Practitioner Name and Degree Practitioner License No. and State TYPE OF NAE NAE Prior Year(s)
(print)
EXAM: Current
National Provider Identifier Comments:
Facility Name
(NPI)
Date Reviewed: I.D. NUMBER
Address City State Zip / /

REVIEWER:
Telephone Fax Email
FORM ID#
CH205 Health Exam 2016_r4-16_FINAL.indd