Form 1 Initial Medical Exam Form

OMB Control No: 0970-XXXX

Expiration date: XX/XX/XXXX

Initial Medical Exam

General Information (to be completed by shelter staff)

Child

Last name:

First name:

DOB: ____/____/______

A#:

Gender:

Healthcare Provider

Name: MD / DO / PA / NP

Phone number:

Clinic or Practice:

Street address:

City or Town:

State:

Date of visit: ____/____/______

Program

Name of program staff with child:

Program name:

History and Physical Assessment (to be completed by provider)

Vital Signs

T (Co):

HR:

BP (> 3 years):

RR:

Ht (cm):

Wt (kg):

Allergies

Check if none

Food, specify:

Medication, specify:

Other, specify:

Vision (> 5 years)

Right Eye

Left Eye

Both eyes

Corrected

20 /

20 /

20 /

Uncorrected

20 /

20 /

20 /

Medical History

Concerns expressed by child or caregiver:

No concerns

Past medical history (include surgeries and hospital admissions):

Family History:

Reproductive History:

LMP: ____ / ____ / ______ or

N/A

Previous pregnancy: G _______ P _______ or

N/A

Review of Systems (ROS)

Check all applicable signs and symptoms and enter the date each began:

No abnormal findings

Pain, location: ____________________

___/____/____

Fever (>37.8 Co) or chills

___/____/____

Red eyes

___/____/____

Runny nose

___/____/____

Sore throat

___/____/____

Cough

___/____/____

Difficulty breathing/Shortness of breath/ Wheezing

___/____/____

Nausea

___/____/____

Vomiting

___/____/____

Diarrhea

___/____/____

Neck stiffness

___/____/____

Headache

___/____/____

Confusion/Altered mental status

___/____/____

Dizziness

___/____/____

Neurologic symptoms

___/____/____

Skin lesions or rash

___/____/____

Yellow skin or eyes

___/____/____

Swollen glands

___/____/____

Unusual bleeding

___/____/____

Other, specify: ___/____/____

Physical Examination
Check each system to indicate if normal or abnormal. If abnormal, describe. Leave blank if not evaluated:
System	Normal	Abnormal
General appearance		Specify:
HEENT		Specify:
Neck		Specify:
Heart		Specify:
Lungs		Specify:
Abdomen		Specify:
GU/GYN		Specify:
Extremities		Specify:
Abdomen		Specify:
Back/Spine		Specify:
Neurologic		Specify:
Skin (include tattoos)		Specify:
Other: _____________		Specify:

Psychosocial Risk
In each section, place a check next to each reported condition/history/behavior & describe where applicable:
Mental Health (Over the past 3 months)						Check if no concerns
Feels empty, hopeless, sad, numb more often than not			Has trouble concentrating, restless, too many thoughts
Feels constantly worried, anxious, nervous more often than not			Has trouble eating, sleeping
Experiences mood swings, from very high to very low			Feels helpless
Reliving traumatic events from the past			Feels like hurting others
Feels easily annoyed or irritated			Feels like hurting self, would be better off dead
Feels afraid, easily startled, jumpy			Other concerns:
Physical Abuse History				Check if abuse is denied
Victim of physical abuse, specify who/when/where: __________________________________________ _____________________________________________________________________________________								In home country
								During journey to U.S.
Sexual Activity/Abuse History					Check if sexual activity or abuse are denied
Consensual sexual activity (oral/vaginal/anal)
Sexual abuse, specify who/when/where: ___________________________________________________ _____________________________________________________________________________________								In home country
								During journey to U.S.
Previous STD, specify: ______________________________________________________________________________________
Substance Abuse				Check if substance use is denied
IVDU:	Alcohol:	Tobacco:					Other:

Laboratory Testing
Ordered	Test	Indicators	Result
			Positive	Negative	Indeterminate
	Flu, rapid	Fever + cough or sore throat
	HIV	> 13 yrs or Sexual activity/abuse
	Pregnancy	>10 yrs or Sexual activity/abuse
	Lead (positive >5 mcg/dl)	6 mos - 6 yrs
	Hepatitis B surface antigen	Sexual activity/abuse, IVDU
	Hepatitis C antibody	IVDU
	Syphilis RPR/VRDL	Sexual activity/abuse
	Chlamydia NAAT	Sexual activity/abuse
	Gonorrhea NAAT	Sexual activity/abuse

TB Screening (Use Appendix A for result documentation)
Has child ever been a close contact to someone with active TB disease?		No		Yes, specify:
Has child ever been treated for active TB disease?		No		Yes, specify:
Has child ever been treated for latent TB infection?		No		Yes, specify:
TB screening method ordered:	TST (any age)		IGRA (5-15 yrs)		CXR (>15 yrs)	Was or will be tested elsewhere

Assessment and Plan

Assessment: Check all that apply. If “Other” is selected, specify in the space provided.

• Well-child (Only check if no other condition present)

General/Constitutional

• Dehydration

• Allergy (drug reaction, food allergy, etc.)

• Malnourished

• Other: _____________________________________

HEENT

• Headache/migraine

• Vision issues

• Hearing issues

• Other: _____________________________________

Respiratory/Pulmonary

• Asthma

• Influenza or influenza-like illness (ILI)

• Upper/lower respiratory illness (not ILI)

• Other: _____________________________________

Cardiovascular

• Heart murmur

• Syncope/fainting

• Other: _____________________________________

Gastrointestinal

• Gastroenteritis

• Heartburn/reflux

• Intestinal parasites (e.g., tapeworms)

• Other: _____________________________________

Genito-urinary/Reproductive

• Childbirth

• Pregnancy/pregnancy-related

• Urinary tract infection

• Other: _____________________________________

Neurological

• Developmental delay

• Seizure/epilepsy

• Other: _____________________________________

Skin and Hair

• Lice

• Scabies

• Dermatitis/rash (not acne)

• Cellulitis

• Other: _____________________________________

Potentially Reportable Infectious Disease

Acute hepatitis A	Acute/chronic hepatitis B
Acute/chronic hepatitis C	Chikungunya
Chlamydia	Dengue
Gonorrhea	HIV
Malaria	Measles
Mumps	Pertussis
Rubella	Sepsis/Meningitis
Syphilis	TB
Typhoid fever	Varicella
Viral hemorrhagic fever, specify: ______________	Other: _______________________

Abuse

• Sexual

• Physical

• Other: _____________________________________

Injury

• Fracture

• Other: _____________________________________

• Other, Medical: _______________________________________

_______________________________________________

Behavioral and Mental Health Concerns

ADHD/ADD	Adjustment disorder
Anxiety disorder	Bipolar disorder
Borderline personality disorder	Depressive disorder
Panic disorder	PTSD
Schizophrenia	Self-injury/cutting
Suicide ideation/attempt	Other: __________________

Plan: Check all that apply and specify in the space provided.

Return to clinic:

• PRN/As needed

• Follow-up (specify condition, timing): _____________________________________________________________________________

• Referred to specialist/counselor: ___________________________________________________________________________________

• Prolonged treatment/therapy (e.g., physical therapy): __________________________________________________________________

• New/Current medications (specify name, reason, date started, dose, and directions and check if psychotropic):

1. ____________________________________________________________________________________________

• Psychotropic

2. ____________________________________________________________________________________________

• Psychotropic

3. ____________________________________________________________________________________________

• Psychotropic

• Immunizations given/validated from foreign record (Please ensure that shelter staff receive a copy of the immunization record)

• List immunizations not given due to medical contraindication: ___________________________________________________________

• Age-appropriate anticipatory guidance discussed and/or handout given

• Other: ________________________________________________________________________________________________________

Additional Information:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.