Form 1 Medical Assessment Form

OMB Control No: 0970-0466

Expiration date: 10/31/2026

Medical Assessment Form Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)

General Information

Child

Last name:

First name:

DOB:

A#:

Gender:

Date evaluated:

Time evaluated:

Primary language: ___________________________

Who provided appropriate language services for child during evaluation?

HCP fluent in child’s primary language

Trained interpreter

Not provided

Evaluating Healthcare Provider (HCP)

Name: MD / DO / PA / NP

Phone number:

Clinic or Practice:

Street address:

City/Town:

State:

Location where child received care (e.g., Primary health care provider/Pediatrician, medical specialist):

Program

Program name:

Program Staff Member Present During Exam with HCP

Reason for visit:

Initial medical exam (IME)*

New complaint/concern

Follow-up visit with PCP for previous complaint/concern

Specialist visit, type: ______________

Routine well-child check/Establish care

History and Assessment*

Vital Signs

Temperature (T)

Heart Rate (HR)

BP (> 3 yrs)

Resp Rate (RR)

Height (HT)

Weight (WT)

BMI (>2 yrs)

BMI %ile

0C

cm

kg

Allergies:

No

Yes, specify below:

Food

Medication

Environmental

Allergen

Reaction

Vision Screening (> 3 years):

Yes, specify below

Not performed

Hearing Screening:

Yes, specify below

Not performed

Right Eye

Left Eye

Both eyes

Final

OAE/ABR (Preferred for < 4 years)

Pass

Fail

Corrected

20 /

20 /

20 /

Pass

Fail

Pure Tone Audiometry (Preferred for ≥ 4 years)

Pass

Fail

Uncorrected

20 /

20 /

20 /

Pass

Fail

Gross Hearing (Acceptable for all ages)

Pass

Fail

Medical & Mental Health History (including dates & locations of care)

Surgeries: _______________________________________________________________________________________________________________________

Hospitalizations: __________________________________________________________________________________________________________________

Chronic/Underlying conditions: _____________________________________________________________________________________________________

Family: _________________________________________________________________________________________________________________________

Healthcare received in DHS custody/during journey: _____________________________________________________________________________________

Medications (dosage frequency & dates):

Past: _____________________________________________________________________________________________________

Current: ___________________________________________________________________________________________________

Reproductive History (complete for anatomically female UC who have started menarche):

Date of LMP: ____ / ____ / _____,

Approximate

Exact

Contraceptive use, specify (e.g., IUD, pills): ____________________________

Pregnancy history:

No

Yes, # of: vaginal deliveries ____, C-sections ____, miscarriages/abortions ____, ectopics ____, living children _____

Pregnancy/Postpartum complications: _____________________________________________________________________

Currently breastfeeding

History of abuse:

Yes, specify

Denied, with no obvious signs

Denied, but obvious signs present

Unknown

Type(s):

Verbal

Emotional

Physical, specify: ______________________________________________________________________

Sexual (with or without penetration), estimated date of last encounter: ___ / ____ / ______

Other victimization (e.g., gang, bullying, crime): _____________________________________________________________________________

Consensual sexual activity (with penetration):

No

Yes, estimated date of last encounter: ____ / ____ / ____

Unknown

Substance use:

Yes, specify

Denied, with no obvious signs/symptoms

Denied, but obvious signs/symptoms present

Unknown

Alcohol

Tobacco/Nicotine

Marijuana

Injection drugs (IDU)

Other substances

Specify substance(s)

N/A

Frequency/Quantity

Date of last use

Travel history: ___________________________________________________________________________________________________________________

Review of Systems (ROS) and Physical Exam*

Concerns expressed by child/caregiver:

No

Yes, specify: Page 1 of 4

Were any physical signs/symptoms reported by the child or observed by program staff or HCP?

No

Yes, check all applicable signs/symptoms and enter the onset date (mm/dd/yyyy):

Sign/Symptom

Pain, location: ____________

Fever (>37.8 Co) or chills

Red Eyes

Runny Nose

Sore Throat

Cough

Difficulty breathing/ Shortness of Breath

Onset Date

Sign/Symptom

Nausea

Vomiting

Diarrhea

Neck stiffness

Headache

Dizziness

Confusion/Altered mental status

Onset Date

Sign/Symptom

Neurologic symptoms

Skin lesions/Rash

Yellow skin/eyes

Swollen glands

Unusual bleeding

Other:

Other:

Onset Date

Physical Examination*

Systems

Normal findings

Abnormal findings, specify or if not evaluated, give reason:

General

Well-appearing/nourished; no distress; developmentally appropriate

Head/Neck

Normocephalic, neck supple; no adenopathy or masses

Eyes

PERRL, EOMI; no redness/discharge

ENT/Dental

TMs WNL; no rhinorrhea; o/p w/o erythema, lesions, caries, abscess

Cardiovascular

Regular rate & rhythm; no murmurs; normal pulses; cap refill < 3 sec

Lungs

Clear to auscultation, no wheezes, crackles, rhonchi, no accessory muscle use

Abdomen

Non-distended; soft and non-tender; no masses or organomegaly

Genitourinary

External GU normal; Tanner _____: no lesions, discharge, hernia

Musculoskeletal/Back/Extremities

Full range of motion of all extremities; no joint swelling, erythema; no scoliosis

Neurologic

Typical gait, strength, tone, sensation, speech & behavior for age

Skin

No rashes, lesions, jaundice, pallor, scars, birthmarks, or tattoos

Other:

Were any mental health signs/symptoms reported by the child or observed by program staff or HCP?

No

Yes, specify below:

Feels empty, hopeless, sad, numb more often than not

Has trouble eating, sleeping

Feels constantly worried, anxious, nervous more often than not

Has nightmares

Experiences mood swings, from very high to very low

Engages in self-harm

Relives traumatic events from the past

Hears voices or sees things others do not see (hallucinations)

Feels easily annoyed or irritated

Thoughts of hurting others

Feels afraid, easily startled, jumpy

Thoughts of hurting self, would be better dead

Has trouble concentrating, restless, too many thoughts

Other concerns: ______________________________________________

Is child able to attribute these feelings to a specific reason(s)?

No

Yes, specify: _____________________________________________________

Laboratory Testing*

Condition

Indicators

Test

Result

CBC w/ diff

<6 yrs at IME

Blood/Serum

Ordered

Pending; collected: ____/____/_____

Lead

<6 yrs, lactating or pregnancy at IME

Capillary, Lead

Negative

Positive (>3.5 μg/dL), level: _____

Blood/Serum, Lead

Ordered

Pending; collected: ____/____/_____

Pregnancy

­>10 yrs or <10 yrs who have reached menarche at IME, sexual activity/abuse/assault

Urine pregnancy

Negative

Positive

Indeterminate

HIV

All children at IME

Rapid, fingerstick/oral

Negative

Positive

Indeterminate

Blood/Serum, 4th Gen

Ordered

Pending; collected: ____/____/_____

Syphilis

<2 yrs & not with biological mother at IME, sexual activity/abuse/assault

RPR/VDRL

Ordered

Pending; collected: ____/____/_____

Chlamydia

Sexual activity/abuse/assault

NAAT/PCR

Ordered

Pending; collected: ____/____/_____

Gonorrhea

Sexual activity/abuse/assault

NAAT/PCR

Ordered

Pending; collected: ____/____/_____

Hepatitis B

Pregnancy, sexual abuse/assault, IDU, country-based

Surface antigen

Ordered

Pending; collected: ____/____/_____

Hepatitis C

Pregnancy, IDU

Total antibody

Ordered

Pending; collected: ____/____/_____

COVID-19

Any COVID-19 symptom, incl. but not ltd. to runny nose, sore throat, cough, headache, diarrhea

Rapid:

Ag

PCR

Negative

Positive

Indeterminate

NAAT/PCR

Ordered

Pending; collected: ____/____/_____

Influenza

Fever + cough or sore throat

Rapid flu

Negative

Positive, type(s):

A

B

Unk

Strep throat

Sore throat + fever without cough, HCP discretion

Rapid strep

Negative,

culture ordered

Positive

Other Reportable Infectious Disease (Non-TB):

Specify:

Ordered

Pending; collected: ____/____/_____

Specify:

Ordered

Pending; collected: ____/____/_____

Page 2 of 4

TB Screening*

Has child ever been exposed to a person with active TB disease?

No

Yes, specify:

Has child ever been treated for TB?

No

Yes, specify type & details:

Active TB disease

Latent TB infection (LTBI)

TB screening indicator

Test

Result

<2 yrs of age at IME

PPD/Tuberculin skin test (TST)

Ordered

Pending; date performed: ____/____/_____, date read: ____/____/______; Result (mm): _____

>2 yrs of age at IME

TB blood test (IGRA): QuantiFERON®-TB Gold In-Tube test (QFT-GIT)

Ordered

Pending; collected: ____/____/_____

T-SPOT®.TB test (T-Spot)

>15 yrs of age at IME

Single view (PA) CXR

Ordered

Pending; performed: ____/____/_____

<15 yrs and + TST/IGRA or exposure/treatment history

2-view (PA and lateral) CXR

Ordered

Pending; performed: ____/____/_____

TB Screening Outcome:

Pending

Negative for TB condition; No further follow up needed

TB, Latent (LTBI)

Referred to Health Department/ specialist for active TB evaluation

Not performed: ____________________

If referred to HD/specialist, was an active TB work-up initiated?

No, specify reason: _______________________________________________________________________________________________

Yes, specify reason:

Signs/Symptoms

Abnormal imaging

Exposure history

Initiation of LTBI treatment

Other: ___________

Specimen collected by HD/specialist:

Specimen type: _______________________

Tests ordered: _____________________________________

Diagnosis and Plan*

Diagnosis: Child with complaints, symptoms, diagnoses/conditions; meds prescribed (including OTC) or referrals needed:

No

Yes

If Yes, check all diagnoses that apply. Specify in the space provided, where indicated.

General/Constitutional

HEENT

Respiratory/Pulmonary

Cardiovascular

Gastrointestinal

Allergic reaction Allergy: _______________ Anemia Dehydration Developmental delay Lead in blood Fatigue Lymphadenopathy Obesity Sickle cell disease Underweight/Weight loss Other: ________________

Allergic rhinitis Cerumen impaction Conjunctivitis Hearing issues: ____________________ Otitis externa Otitis media Pharyngitis, strep Pharyngitis, other Vision issues: ____________________ Other: ______________

Abnormal CXR (Non-TB): ____________________ Asthma, severity: _________ Bronchiolitis Chronic cough Croup Influenza, lab-confirmed Influenza-like illness (ILI) Pneumonia Shortness of breath/wheezing Upper respiratory illness Other: ___________________

Arrhythmia Chest pain Congenital heart disease: ____________________ High blood pressure Heart murmur Myocarditis/Pericarditis/ Endocarditis Syncope/Fainting Other: _______________

Abdominal pain Appendicitis Constipation Diarrhea, acute/chronic Failure to thrive Gastritis/Peptic ulcer Gastroenteritis GI bleeding Heartburn/Reflux Inflammatory bowel disease Intestinal parasites: ____________________ Jaundice Liver disease Nausea/Vomiting Other: ______________

Dental

Endocrine Disorder

Broken tooth/teeth Gingivitis/Gum disease Impacted tooth/teeth Infection/abscess

Missing tooth/teeth Tooth decay/caries Tooth sensitivity Other: _____________

Acanthosis nigricans Delayed/Precocious puberty Diabetes, Type 1 and 2

Hyper/Hypothyroidism Short stature Other: _______________

Genito-urinary/Reproductive

Musculoskeletal

Potentially Reportable Infectious Disease

Abnormal vaginal discharge Abortion Amenorrhea/Abnormal uterine bleeding Bed-wetting Childbirth Consensual sexual activity Genital lesions Gynecomastia/Breast mass Herpes simplex virus Inguinal hernia

Kidney disease/stones Menstrual cramping/pain Miscarriage Pelvic inflammatory disease Pregnant, gestational age: _____ wks; est. due date: ___/____/______ Proteinuria/Hematuria Sexual abuse/assault Testicular pain/Torsion Urinary tract infection Other: _______________

Back pain Bone tumors (benign/malignant) Extremity/Joint pain Fracture Hematoma/Bruise Ligamentous/Tendon injury Myalgia Scoliosis/Kyphosis Sprain/Strain Other: ________________

Acute hepatitis A Acute/chronic hepatitis B Acute/chronic hepatitis C Chikungunya Chlamydia COVID-19 Dengue Gonorrhea HIV Malaria Measles Mumps

Pertussis Rubella Sepsis/Meningitis Syphilis TB, active disease TB, latent (LTBI) Typhoid fever Varicella Zika virus Viral hemorrhagic fever: ____________________ Other: _______________

Neurological

Skin, Hair, and Nails

Brain tumor Cerebral palsy Cerebrovascular disease Headache/Migraine Seizure/Epilepsy

Traumatic brain injury/ Concussion Vertigo/Dizziness Weakness Other: _______________

Acne Atopic dermatitis/Eczema Cellulitis/Abscess Contact dermatitis Diaper rash Hair loss/Alopecia areata

Impetigo Ingrown toenail Lice Onychomycosis Scabies Scars

Tattoos Tinea pedis/corporis/ cruris/capitis Urticaria Warts Page 3 of 4 Other: _______________

Medical, Other

Behavioral and Mental Health Concerns

Anxiety symptoms (e.g., panic attacks, excessive worry/fear)

Depressive symptoms

Manic symptoms (e.g., elated mood, pressured speech)

Trauma symptoms (e.g., nightmares, flashbacks)

Hallucinations

Delusions

Behavioral concerns (e.g., aggression, trouble following rules)

Social/Emotional delay

Urge for/current self-harm

Urge for/current harm to others

History of psychiatric diagnoses or treatment: __________________________________________________

Other: _________________________________________________

Plan: Check all that apply and specify where indicated. Please provide copies of office notes, lab/imaging results, and immunization records to program staff.

• Immunizations administered during visit

• Immunizations documented on foreign record reviewed and validated

• Immunizations indicated but not given; specify: ______________________________________________________________________________________

________________________________________________________________________________________________________________________________

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

• Child educated on healthcare services received and treatment recommendations

• Medications administered/prescribed:

Medication Name	Reason	Date Started	Expected end date	Dose	Directions	Psychotropic?

• Child requires isolation for a communicable disease; specify diagnosis, start/end dates: ______________________________________________________

• Child has special healthcare needs that require accommodation while admitted in ORR care; specify condition/reason, time frame and frequency:

• Onsite care provider clinician evaluation: _______________________________________________________________________________________

• Increased level of supervision for mental health concern: ____________________________________________________________________________

• Assistance with daily living activities: ____________________________________________________________________________________________

• Durable medical equipment: ___________________________________________________________________________________________________

• Physical activity restrictions: ___________________________________________________________________________________________________

• Dietary restrictions: __________________________________________________________________________________________________________

• Other: _____________________________________________________________________________________________________________________

• Child has/may have an ADA disability: ______________________________________________________________________________________________

• Child has health concerns that require follow-up services; specify needs and time frame by when services should occur:

• Return to clinic: _____________________________________________________________________________________________________________

• Mental health specialist evaluation: _____________________________________________________________________________________________

• Medical specialist evaluation: __________________________________________________________________________________________________

____________________________________________________________________________________________________

• Physical/Occupational/Speech therapy: __________________________________________________________________________________________

• Surgery/Procedure needed/performed: __________________________________________________________________________________________

• Other, specify: ______________________________________________________________________________________________________________

Child cleared to travel:

• Yes, with no restrictions

• Yes, with restrictions (e.g., ground travel, travel safety plan, travel length): __________________________________________________

• No, reason: _____________________________________________________________________________________________________

Recommendations from Healthcare Provider / Additional Information

Healthcare Provider Signature: ______________________________________________________________ Date: _______ / ______ / __________

Healthcare Provider Printed Name: ___________________________________________________________

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 13 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0466 and the expiration date is 10/31/2026. If you have any comments on this collection of information, please contact [email protected].

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