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Fill in Your Child Adolescent Health Template

The Child Adolescent Health Examination Form is a crucial document utilized by the NYC Department of Health and Mental Hygiene in collaboration with the Department of Education. This form collects essential information about a child's health, development, and medical history, ensuring that healthcare practitioners can provide appropriate care and support. By thoroughly completing this form, parents and guardians play a vital role in safeguarding their child's well-being and educational success.

Table of Contents

The Child and Adolescent Health Examination Form is a crucial tool designed to ensure the well-being of young individuals as they navigate their formative years. This comprehensive document collects essential information from parents or guardians, including the child’s personal details such as name, date of birth, and address, as well as their race and ethnicity. It also inquires about the child’s health insurance status, allowing for a clearer understanding of their healthcare access. Health care practitioners utilize this form to document vital medical histories, including birth details, any past or present medical conditions, and allergies. A thorough physical examination section captures critical metrics like height, weight, and blood pressure, while developmental screenings assess cognitive, social, and emotional growth. Immunization records are meticulously documented to ensure compliance with public health standards. Furthermore, the form provides space for practitioners to outline any diagnoses, recommendations for follow-up, and referrals to specialists, thereby creating a holistic view of the child's health and developmental needs. By gathering this information, the form plays a vital role in promoting the health and development of children and adolescents in New York City.

Sample - Child Adolescent Health Form

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

↓ Child Adolescent Health PDF

File Specs

Fact Name	Description
Purpose of the Form	The Child Adolescent Health Examination Form is designed to collect essential health information about children and adolescents for school and health services.
Completion Requirement	This form must be filled out by a parent or guardian to ensure accurate health history and current medical status.
Demographic Information	It requires detailed demographic information, including the child's name, date of birth, and address, as well as the parent's contact details.
Health History	Parents or guardians must provide a comprehensive health history, including any past medical conditions, allergies, and medications.
Physical Examination	A section is designated for health care practitioners to document the results of the physical examination, including growth metrics and developmental assessments.
Immunization Records	It includes a section for documenting immunizations, which is critical for school enrollment and public health tracking.
Governing Laws	This form is governed by New York State Education Law and Public Health Law, ensuring compliance with state regulations regarding child health assessments.

Child Adolescent Health - Usage Guidelines

Completing the Child Adolescent Health form is an important step in ensuring that your child's health needs are properly documented. This form collects essential information about your child's medical history, current health status, and any specific needs they may have. Follow the steps below to fill out the form accurately.

Begin with your child's information: Write the child's last name, first name, and middle name. Indicate their sex by checking the appropriate box (Female or Male). Enter the date of birth in the format Month/Day/Year.
Provide the child's address: Fill in the complete address, including city, state, and zip code.
School/Center/Camp details: Write the name of the school, center, or camp the child attends, along with the district.
Contact information: List your phone numbers, including home and cell. If applicable, provide the parent or guardian's last name, first name, and email address.
Health insurance: Indicate if the child has health insurance and whether it includes Medicaid.
Birth history: Check the appropriate box for the child's birth history and provide details if the child was premature or has any complications.
Medical history: Check any relevant medical conditions, allergies, or medications. If necessary, explain any checked items in the space provided.
Physical exam section: Fill in the date of the exam and record the child's height, weight, and BMI. Check the appropriate boxes for physical exam results.
Developmental screening: Complete the nutrition and hearing sections, including any dietary restrictions or concerns.
Immunizations: Record the dates of immunizations and any relevant titers. Make sure to include all required vaccines.
Assessment and recommendations: Indicate if the child is well or has any diagnoses/problems. Provide recommendations for physical activity and follow-up appointments if needed.
Signature and date: The health care practitioner must sign and date the form, providing their name, license number, and facility information.

Your Questions, Answered

What is the purpose of the Child Adolescent Health form?

The Child Adolescent Health form is designed to collect essential health information about children and adolescents. It helps healthcare practitioners assess the overall health, development, and medical history of a child. This information is crucial for identifying any health issues and ensuring that children receive appropriate care and services.

Who needs to complete the form?

The form must be completed by a parent or guardian of the child. If the child is in foster care, the foster parent can also fill out the form. It is important that the information provided is accurate and up-to-date to facilitate proper health assessments.

What information is required on the form?

The form requires basic information such as the child's name, date of birth, address, and school. It also asks about the child's medical history, including any past or present health conditions, medications, allergies, and developmental milestones. Additionally, it includes sections for physical examination results and immunization records.

What should I do if my child has a medical condition?

If your child has a medical condition, you should provide detailed information on the form. This includes specifying the condition, any treatments or medications, and the current status of the condition. If your child requires medication during school hours, make sure to attach the necessary medication administration form (MAF) to the health form.

How is the information on the form used?

The information collected is used by healthcare practitioners to evaluate the child's health and development. It may also be shared with school staff to ensure that any special health needs are addressed. However, all personal information is kept confidential and is only used for health-related purposes.

What if my child has not received all required vaccinations?

If your child has not received all required vaccinations, it's essential to indicate this on the form. You should also discuss with your healthcare provider about scheduling any missed vaccinations. Keeping immunizations up-to-date is vital for your child's health and for preventing the spread of diseases in schools and communities.

Can I update the form after it has been submitted?

Yes, you can update the form if there are any changes in your child's health status or if new medical information becomes available. It is important to keep the school and healthcare providers informed to ensure that your child receives the best care possible.

How often should the Child Adolescent Health form be completed?

The form should be completed annually or whenever there are significant changes in your child's health status. Regular updates help ensure that healthcare providers have the most current information, which is essential for effective monitoring and care.

Common mistakes

Illegible handwriting: Many individuals fill out the form in a hurried manner, resulting in unclear handwriting. This can lead to misinterpretation of critical information.
Incomplete sections: Some people forget to fill out all required fields, such as the child's address or parent/guardian contact information. Missing information can delay processing and follow-up.
Incorrect dates: Entering the wrong date of birth or other important dates can create significant issues. Double-checking dates is essential to ensure accuracy.
Failure to check all relevant boxes: When indicating the child's medical history or race, individuals often neglect to check all applicable boxes. This oversight can impact the child’s health assessment.
Not providing additional details: When checking conditions like asthma or allergies, some fail to provide necessary explanations or details. This lack of information can hinder proper care.
Omitting signatures: Lastly, some individuals forget to sign the form. A missing signature can render the form invalid and require resubmission.

Documents used along the form

The Child Adolescent Health form is essential for gathering comprehensive health information about a child or adolescent. It is often accompanied by several other forms and documents that help ensure a thorough understanding of the child's health needs. Below is a list of commonly used documents that complement the Child Adolescent Health form.

Health Insurance Information Form: This document collects details about the child's health insurance coverage, including policy numbers and provider information, ensuring that necessary medical services can be accessed.
Immunization Records: This form provides a history of the child's vaccinations, which is crucial for ensuring compliance with school and health regulations.
Medication Administration Form (MAF): Used to document any medications that need to be administered during school hours, ensuring proper care and monitoring of the child's health.
Emergency Contact Form: This form lists individuals who can be contacted in case of an emergency, ensuring that someone is available to make decisions about the child's care if needed.
Behavioral Health Assessment: This document evaluates the child's mental and emotional well-being, identifying any areas that may require additional support or intervention.
Developmental Screening Tools: These tools assess various developmental milestones, helping to identify any delays or concerns early on.
Dental Health Form: This form gathers information about the child's dental history and any current dental needs, ensuring comprehensive health care.
Physical Activity Consent Form: This document obtains parental consent for the child to participate in physical activities, addressing safety and liability concerns.

These documents work together to provide a complete picture of a child's health, ensuring that their needs are met effectively. Having all relevant information on hand helps healthcare providers, educators, and families collaborate to support the child's well-being.

Similar forms

The Child Health Assessment form is similar to the School Health Record, which tracks a child's health history and medical needs while attending school. Both documents require information about the child's medical history, immunizations, and any health concerns that may affect their ability to participate in school activities. They are both designed to ensure that schools have the necessary health information to provide a safe environment for students.

Another comparable document is the Immunization Record. This form specifically focuses on a child's vaccination history, detailing the dates and types of vaccines received. Like the Child Adolescent Health form, it is essential for ensuring that children are up-to-date on their immunizations, which is often a requirement for school entry and participation in certain activities.

The Developmental Screening form shares similarities with the Child Adolescent Health form in that it assesses various aspects of a child's growth and development. Both forms include sections for evaluating physical, emotional, and social development, helping parents and healthcare providers identify any potential developmental delays or concerns early on.

The Physical Examination form is another document that aligns closely with the Child Adolescent Health form. It provides a comprehensive overview of a child's physical health through a detailed examination. Both forms require similar measurements, such as height, weight, and blood pressure, and they help healthcare providers monitor a child's overall health and well-being.

The Health History Questionnaire is akin to the Child Adolescent Health form as it collects vital information regarding a child's past medical history, family health history, and current health status. Both documents aim to give healthcare providers a complete picture of the child's health, allowing for better-informed medical decisions.

The Consent for Treatment form is also related, as it often accompanies health assessments. This document ensures that parents or guardians give permission for medical evaluations and treatments. Like the Child Adolescent Health form, it emphasizes the importance of parental involvement in a child's healthcare journey.

Lastly, the Emergency Contact Form shares similarities with the Child Adolescent Health form in that it collects essential information about whom to contact in case of an emergency. Both forms prioritize the safety and well-being of the child, ensuring that caregivers have access to critical health information and emergency contacts when needed.

Dos and Don'ts

When filling out the Child Adolescent Health form, it is crucial to ensure accuracy and clarity. Here are four essential do's and don'ts to consider:

Do print clearly to ensure all information is legible.
Do provide complete and accurate medical history, including any past or present conditions.
Don't leave any sections blank; if information is not applicable, indicate that clearly.
Don't forget to attach any necessary documents, such as the Medical Authorization Form (MAF), if in-school medications are needed.

Misconceptions

Here are four common misconceptions about the Child Adolescent Health form:

It is only for children with health issues. Many believe that this form is only necessary for children with existing health problems. In reality, it is designed for all children and adolescents to ensure comprehensive health assessments.
Parents can skip sections they find irrelevant. Some parents think they can omit certain sections if they don’t apply to their child. However, every section is important for providing a complete picture of the child’s health.
Only medical professionals can fill it out. While healthcare practitioners complete the medical sections, parents or guardians must provide accurate information about their child's history and current health status.
It’s not important for school enrollment. Many parents underestimate the form's significance in school settings. This form is often required for enrollment and helps schools understand the health needs of their students.

Key takeaways

Filling out the Child Adolescent Health form is an important process for ensuring your child's health needs are met. Here are key takeaways to keep in mind:

Complete the form accurately: Provide clear and accurate information about your child, including their name, date of birth, and address.
Check all relevant boxes: Indicate any medical history, allergies, or medications your child is currently taking. This information is crucial for healthcare providers.
Use clear handwriting: Print all information clearly to avoid misunderstandings. Illegible writing can lead to errors in your child's health records.
Include contact information: Make sure to provide current phone numbers for both home and cell, as well as an email address for communication.
Attach necessary documents: If your child requires in-school medications, attach the Medication Administration Form (MAF) as instructed.
Review the physical exam section: Ensure that the healthcare practitioner completes this section thoroughly, noting any abnormalities or health concerns.
Keep a copy: After submitting the form, retain a copy for your records. This can be helpful for future appointments or emergencies.
Follow up: If the form indicates any follow-up appointments or referrals, make sure to schedule them promptly to ensure your child's health needs are addressed.