OMB Control No:
0970-XXXX
Expiration date: XX/XX/XXXX
Initial Medical Exam |
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General Information (to be completed by shelter staff) |
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Child
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Last name: |
First name:
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DOB: ____/____/______ |
A#:
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Gender: |
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Healthcare Provider |
Name: MD / DO / PA / NP |
Phone number: |
Clinic or Practice:
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Street address: |
City or Town: |
State: |
Date of visit: ____/____/______ |
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Program |
Name of program staff with child: |
Program name:
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History and Physical Assessment (to be completed by provider) |
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Vital Signs |
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T (Co): |
HR: |
BP (> 3 years): |
RR: |
Ht (cm): |
Wt (kg): |
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Allergies |
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Vision (> 5 years) |
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Right Eye |
Left Eye |
Both eyes |
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Corrected |
20 / |
20 / |
20 / |
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Uncorrected |
20 / |
20 / |
20 / |
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Medical History |
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Concerns expressed by child or caregiver:
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Past medical history (include surgeries and hospital admissions):
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Family History:
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Reproductive History:
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LMP: ____ / ____ / ______ or |
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Previous pregnancy: G _______ P _______ or |
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Review of Systems (ROS) |
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Check all applicable signs and symptoms and enter the date each began: |
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Physical Examination |
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Check each system to indicate if normal or abnormal. If abnormal, describe. Leave blank if not evaluated: |
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System |
Normal |
Abnormal |
General appearance |
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HEENT |
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Neck |
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Heart |
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Lungs |
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Abdomen |
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GU/GYN |
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Extremities |
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Abdomen |
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Back/Spine |
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Neurologic |
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Skin (include tattoos) |
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Other: _____________ |
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Psychosocial Risk |
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In each section, place a check next to each reported condition/history/behavior & describe where applicable: |
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Mental Health (Over the past 3 months) |
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Physical Abuse History |
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_____________________________________________________________________________________ |
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Sexual Activity/Abuse History |
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_____________________________________________________________________________________ |
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Substance Abuse |
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Laboratory Testing |
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Ordered |
Test |
Indicators |
Result |
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Positive |
Negative |
Indeterminate |
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Flu, rapid |
Fever + cough or sore throat |
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HIV |
> 13 yrs or Sexual activity/abuse |
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Pregnancy |
>10 yrs or Sexual activity/abuse |
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Lead (positive >5 mcg/dl) |
6 mos - 6 yrs |
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Hepatitis B surface antigen |
Sexual activity/abuse, IVDU |
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Hepatitis C antibody |
IVDU |
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Syphilis RPR/VRDL |
Sexual activity/abuse |
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Chlamydia NAAT |
Sexual activity/abuse |
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Gonorrhea NAAT |
Sexual activity/abuse |
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TB Screening (Use Appendix A for result documentation) |
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Has child ever been a close contact to someone with active TB disease? |
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Has child ever been treated for active TB disease? |
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Has child ever been treated for latent TB infection? |
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TB screening method ordered: |
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Assessment and Plan |
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Assessment: Check all that apply. If “Other” is selected, specify in the space provided.
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General/Constitutional
HEENT
Respiratory/Pulmonary
Cardiovascular
Gastrointestinal
Genito-urinary/Reproductive
Neurological
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Skin and Hair
Potentially Reportable Infectious Disease
Abuse
Injury
_______________________________________________
Behavioral and Mental Health Concerns
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Plan: Check all that apply and specify in the space provided. |
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Return to clinic:
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Additional Information:
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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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Buckley, Kirsten (CDC/OID/NCEZID) |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |