Document
Medical Assessment Form
ICR 202610-0970-004 · OMB 0970-0466 · Object 174226800.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Medical Assessment Form |
| Author | Buckley, Kirsten (CDC/OID/NCEZID) |
| Last Modified By | Writer |
| File Modified | 2025-02-07 |
| File Created | 2026-10-28 |
| Conversion State | complete |
Extracted Text
Medical Assessment Form
Unaccompanied Alien Children Bureau
Office of Refugee Resettlement (ORR)
General Information
Child
Last name:
First name:
DOB:
A#:
Sex:
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:
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
• 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: _________________________________________________
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].