Medical Assessment Form - Specialist, General

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Medical Assessment Form (MAF) 
Unaccompanied Alien Children Bureau
Office of Refugee Resettlement (ORR)
Instructions: The MAF must be completed by the evaluating healthcare provider (MD, DO, NP, PA, or PhD) as follows - Initial Medical Exam (IME), all 4 pages are required; routine well-child visits, pages 1-3 are required; all other scheduled assessments (e.g., PCP sick/follow-up visits, establish care visits, specialist visits), pages 1 & 2 are required, and page 3 is recommended. All healthcare providers must complete the ‘Acknowledgement’ section on page 3. Please refer to the MAF ‘Dear Colleague’ letter for additional guidance. 
Child & Visit Information
Last name:

First name:
DOB:
Sex:
Setting:
    • In-person;
    • medical chaperone present for all/part of the physical exam
Date evaluated:
Time evaluated:
                                  AM / PM

    • Telehealth



Visit type: 
    • IME
    • Routine well-child
    • Other preventive care (e.g., establish care, follow-up immunizations, counseling), specify: _________________________________________________________

    • New complaint
    • Referral/Follow-up

Was an interpreter or translation service used in the performance of this assessment?
    • No

    • Yes, specify mode of service used during assessment: ___________________________________
Chief complaint/History of present illness as reported by child and/or care provider staff:





 
Visit Summary
Temperature
Heart Rate
Resp Rate
o2 Sat
BP (> 3 yrs)
Height
Weight
           
                            0C




                             cm                                        
                               kg                                                                                     
Allergies:
    • No
    • Yes, specify, including reaction:
    • Food: ______________________________________________________________________________________________________________________
    • Medication: _________________________________________________________________________________________________________________
    • Environmental: ______________________________________________________________________________________________________________

Significant medical/mental health symptoms and exam findings (skip if page 3 will be completed):















Assessment & Plan (Required for all visits)
Diagnoses: Note, please enter mental health concerns (e.g., anxiety symptoms, self-harm, trauma symptoms) instead of diagnoses when additional work-up is needed by a mental health professional (no ICD code needed)
ICD Code
Diagnosis/Mental Health Concern
Referrals & Follow-up appts. (e.g., Return to Clinic, PCP, OB/GYN, ER, Psychiatry, Dentist, PT, Mental health therapy)
Timeframe/Date, 
if applicable

























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 0.135 hours per respondent, 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 (see, 45 CFR §§410.1306(g);410.1307). 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 XX/XX/XXXX. If you have any comments on this collection of information, please contact [email protected].
Plan: All fields required; please specify as indicated.
    • No
    • Yes
Immunizations administered during visit (please provide immunization record by end of visit)
    • No
    • Yes
Immunizations indicated, but not given and reason why: ________________________________________________________________
_______________________________________________________________________________________________________________
    • No
    • Yes
Procedures performed:  ___________________________________________________________________________________________
    • No
    • Yes
Lab testing/imaging ordered/performed (including point-of-care tests, e.g., Flu, Strep) & status (Ordered, Collected) or result: 
(Note, document all IME lab testing/imaging on page 4):


Medical & Social History
Breastfeeding
    • No
    • Yes
    • N/A
Past medical history including hospitalizations and surgeries:

 

 History of sexual activity:
    • No
    • Yes, estimated date of last encounter___ /___ /_____
    • No response
History/Evidence of abuse:
    • Denied
    • Denied, but HCP concern
    • Yes, specify below: 
    • No response
    • Verbal/Emotional 
    • Physical
    • Sexual abuse, est. date of last encounter: ___ / ___/ _____
    • Other: ______________________________
Substance use:
    • Denied
    • Denied, but HCP concern
    • Yes, specify below: 
    • No response
Substance
Freq of use
DLU
Substance
Freq of use
DLU
Substance
Freq of use
DLU
Alcohol


Ecstasy


Nicotine (e.g., cigarettes, vaping)


Marijuana


PCP


Inhalants


Other depressants


Other stimulants


Hallucinogens or Psychedelics (e.g., LSD, mushrooms, mescaline)


Cocaine


Heroin





Crack


Other opiates








1 Siblings of children with known elevated lead levels must also be screened for lead.
2 As of October 2026, areas with ≥2% prevalence include much of Asia, the Pacific Islands, and most countries in Africa, particularly sub-Saharan Africa, as well as select countries in Europe, Latin America, and the Caribbean.