Med Form

CHILD & ADOLESCENT HEALTH EXAMINATION FORM NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION
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CSTUDENT ID NUMBER OSIS
TO BE COMPLETED BY PARENT OR GUARDIAN
Child’s Last Name
 First Name
 Middle Name
Sex
 Famele Male 		Date of Birth (Month/Day/Year )
Child’s Address
Hispanic/Latino?
 Yes No 		Race (Check ALL that apply)
 American Indian Asian Black White Native Hawaiian/Pacific Islande Other
City/Borough
 State
 Zip Code
School/Center/Camp Name
BIG APPLE SUMMER CAMP 		District
Number
 Parent/Guardian Foster Parent Last Name
 First Name

Health insurance (including Medicaid)

 Yes No

Phone Numbers

Home
Cell
Work

TO BE COMPLETED BY HEALTH CARE PROVIDER If “yes” to any item, please explain (attach addendum, if needed)

Birth history (age 0-6 yrs)

 Uncomplicated Premature
 Complicated by
Allergies  None Epi pen prescribed
 Drugs (list)
 Foods (list)
 Other (list)

Does the child/adolescent have a past or present medical history of the following?

 Asthma (check severity and attach MAF/Asthma Action Plan): Intermittent Mild Persistent Moderate Persistent Severe Persistent If persistent, check all current medication(s): Inhaled corticosteriod Other controller Quick relief med Oral steroid None

 Attention Deficit Hyperactivity Disorde
 Chronic or recurrent otitis media
 Congenital or acquired heart disorder
 Developmental/learning problem
 Diabetes (attach MAF) 		 Orthopedic injury/disability
 Seizure disorder
 Speech, hearing, or visual impairment
 Tuberculosis (latent infection or disease)
 Other (specify)

Medications (attach MAF if in-school medication needed)

 None Yes (list below)

Dietary Restrictions
 None Yes (list below)

PHYSICAL EXAMINATION

Heigh cm     (%lle)
Weight kg     (%lle)
BMI kg/m2     (%lle)
Head Circumference (age ≤2 yrs cm (%lle)
Blood Pressure (age ≥3 yrs) /

General Appearance:
HEENT  Nl Abnl
Dental  Nl Abnl
Neck  Nl Abnl 		Lymph nodes  Nl Abnl
Lungs  Nl Abnl
Cardiovascular  Nl Abnl
Abdomen  Nl Abnl
Genitourinary  Nl Abnl
Extremities  Nl Abnl 		Skin  Nl Abnl
Neurological  Nl Abnl
Back/spine  Nl Abnl 		Psychosocial Development  Nl Abnl
Language  Nl Abnl
Behavioral  Nl Abnl

Describe abnormalities:

DEVELOPMENTAL

(age 0-6 yrs)  Within normal limits
If delay suspected, specify below
 Cognitive (e.g., play skills)
 Communication/Language
 Social/Emotional
 Adaptive/Self-Help
 Motor

SCREENING TESTS Date Done Results

Blood Lead Level (BLL)

(required at age 1 yr and 2 yrs
and for those at risk)


µg/dL
µg/dL

Lead Risk Assessment

(annually, age 6 mo-6 yrs)

 At risk (do BLL)
 Not at risk

Hearing

 Pure tone audiometry
 OAE

 Normal
 Abnormal
Head Start Only
Hemoglobin or
Hematocrit (age 9–12 mo) 		g/dL
%
Date Done Results

Tuberculosis

 Only required for students entering intermediate/middle/junior or high school
who have not previously attended any NYC public or private school
PPD/Mantoux placed
PPD/Mantoux read
Induration mm
 Neg Pos
Interferon Test  Neg Pos
Chest x-ray
(if PPD or Interferon positive) 		 Nl Not Abnl

Vision

(required for new school entrants
and children age 4–7 yrs)


 with glasses 		Acuity Right /
Left /
Strabismus  No Yes

IMMUNIZATIONS – DATES

 CIR Number of Child
Hep B
Rotavirus
DTP/DTaP/DT


Hib
PCV
Polio
Influenza
MMR
Varicella
Td
Tdap Hep A
Meningococcal
HPV
Other, specify:
RECOMMENDATION  Full physical activity Full diet
 Restrictions (specify)
Follow-up Needed  No Yes for Appt. date:
Referral(s):  None Early Intervention Special Education Dental Vision Other
ASSESSMENT
 Well Child (V20.2) Diagnoses/Problems (list) 		ICD-9 Code
Health Care Provider Signature Date:
Health Care Provider Name and Degree (print) Provider License No. and State
Facility Name National Provider Identifier (NPI)
Address
City
State
Zip
Telephone
Fax
DOHMH ONLY PROVIDER I.D
TYPE OF EXAM:  NAE Current NAE Prior Year(s)
Comments
Date Reviewed:
I.D. NUMBER
REVIEWER

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