Form 1 Initial Medical Exam Form

O MB Control No: 0970-0466 Expiration date: XX/XX/XXXX

Initial Medical Exam Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)

General Information (to be completed by program 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 (to be completed by healthcare 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 1, specify: ___/____/____

Other 2, specify: ___/____/____

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Physical Examination

Check each system to indicate if normal or abnormal and describe. Leave blank if not evaluated:

System

Normal

Abnormal

Describe

General appearance

HEENT

Neck

Heart

Lungs

GU/GYN

Extremities

Abdomen

Back/Spine

Neurologic

Skin (include tattoos)

Other: _______________

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

Relives 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 physical abuse is denied

Victim of physical abuse, specify who/when/where: ___________________________ ____________________________________________________________________________________________________________________________________________

In home country

During journey to U.S.

In US, not in ORR custody

In ORR custody

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.

In US, not in ORR custody

In ORR custody

Previous STD diagnosis, specify: ___________________________________________________________________________________

Substance Use

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/IVDU

Hepatitis C antibody

IVDU

Syphilis RPR/VRDL

Sexual activity/abuse

Chlamydia NAAT

Sexual activity/abuse

Gonorrhea NAAT

Sexual activity/abuse

TB Screening (Use Supplemental TB Screening form 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

IGRA

CXR

Was or will be tested elsewhere

Assessment and Plan

Assessment:

Child without complaints, symptoms, diagnoses/conditions; no meds (including OTC) or referrals needed:

• No

• Yes

If No, check all diagnoses that apply. If “Other” is selected, specify in the space provided.

General/Constitutional

Allergy (e.g., drug reaction, food allergy), specify: ________________________________
Dehydration	Malnourished
Other: _________________________________

HEENT

Headache/Migraine	Hearing issues
Otitis media/Ear infection	Pharyngitis (Not strep throat)
Rhinitis	Strep throat
Vision issues	Viral/Bacterial Conjunctivitis
Other: _________________________________

Respiratory/Pulmonary

Asthma	Influenza-like illness (ILI)
Influenza, lab-confirmed; specify: ______________
Upper/lower respiratory illness; specify: _______________________________________
Other: _________________________________

Cardiovascular

Heart murmur	Syncope/fainting
Other: _________________________________

Gastrointestinal

Abdominal pain	Gastroenteritis
Heartburn/reflux	Intestinal parasites
Other: ________________________________

Genito-urinary/Reproductive

Childbirth	Pregnancy/Pregnancy-related
Genital warts	Urinary tract infection
Other: ________________________________

Neurological

• Developmental delay

• Seizure/epilepsy

• Other: ________________________________

Musculoskeletal

Back pain	Fracture
Leg pain	Sprain/Strain
Other: ________________________________

Skin, Hair, and Nails

Cellulitis	Dermatitis/Rash (not acne)
Ingrown toenail	Lice
Scabies	Tinea pedis
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: ______________	Zika virus

• Other: _______________________________

Abuse

• Sexual; where/when: ____________________________

• Physical; where/when: ___________________________

• 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 indicate if psychotropic):

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

• Immunizations given/validated from foreign record

• List immunizations not given due to medical contraindication: ___________________________________________________________

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

• Child quarantined/isolated at the program for a diagnosis, specify: _______________________________________________________

• Release of child delayed from the program because of a diagnosis, specify: _________________________________________________

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• Other: ________________________________________________________________________________________________________

­________________________________________________________________________________________________________

Additional Information

Potentially Reportable Infectious Diseases
Lab testing performed to confirm the diagnosis:			No	Yes
Health department notified by program:			No	Yes	Not applicable
Intakes delayed/postponed because of this diagnosis:			No	Yes
UAC exposed to this child while infectious:			No	Yes (Complete a Contact Investigation Form for each exposed UAC)
Number of staff members exposed to this diagnosis:
Potentially Reportable Infectious Disease (Non-TB) Lab Testing
Disease Tested	Collection Date	Specimen Type (e.g., Serum)				Test Type (e.g., IgM)	Result

Please provide copies of office notes, lab/imaging results, and immunization records to program staff.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 10 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.

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