Blank Child Adolescent Health Template

The Child and Adolescent Health Examination Form is an essential document required by the NYC Department of Health & Mental Hygiene and the Department of Education. This form gathers vital information about a child's health, including their medical history, physical exam results, and developmental screenings. To ensure the well-being of your child, please fill out the form by clicking the button below.

Article Guide

The Child Adolescent Health form is an essential resource for parents and guardians in New York City that helps ensure the health and well-being of children from infancy through adolescence. This comprehensive document gathers crucial information about a child's medical history, including vaccination records, birth history, and any existing health issues. Parents are prompted to provide details related to their child’s growth measurements, physical exam results, and developmental screenings. The form also addresses important health factors such as allergies, medication requirements, and specific developmental concerns. An important component is the section dedicated to the healthcare practitioner’s evaluation, which includes assessments of general appearance, nutrition, vision, and hearing capabilities. Collectively, this information empowers caregivers and educators to identify health needs and coordinate appropriate interventions, making the Child Adolescent Health form a pivotal tool in fostering a supportive environment for the growth of young individuals.

Form Sample

CHILD & ADOLESCENT HEALTH EXAMINATION FORM

NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION

Please Print Clearly

NYC ID (OSIS)

TO BE COMPLETED BY THE PARENT OR GUARDIAN

Child’s Last Name

First Name

Middle Name

Sex ☐ Female

☐Male

Date of Birth (Month/Day/Year )

___ ___ / ___ ___ / ___ ___ ___ ___

Child’s Address

Hispanic/Latino?

Race (Check ALL that apply)

☐ American Indian ☐ Asian

☐ Black

☐ White

☐ Yes

☐ No

☐ Native Hawaiian/Pacific Islander

☐ Other _____________________________

City/Borough

State

Zip Code

School/Center/Camp Name

District

__ __

Phone Numbers

Number __ __ __

Home ___________________

Cell

_________

Health insurance

☐ Yes

☐ Parent/Guardian Last Name

First Name

(including Medicaid)? ☐ No

☐ Foster Parent

Work

TO BE COMPLETED BY THE HEALTH CARE PRACTITIONER

Birth history (age 0-6 yrs)

Does the child/adolescent have a past or present medical history of the following?

☐ Uncomplicated ☐ Premature: ______ weeks gestation

☐ Asthma (check severity and attach MAF):

☐ Intermittent

☐ Mild Persistent

☐ Moderate Persistent

☐ Severe Persistent

If persistent, check all current medication(s):

☐ Quick Relief Medication

☐ Inhaled Corticosteroid

☐ Oral Steroid ☐ Other Controller

☐ None

☐ Complicated by

_________________________________

Asthma Control Status

☐ Well-controlled

☐ Poorly Controlled or Not Controlled

Allergies ☐ None ☐ Epi pen prescribed

☐ Anaphylaxis

☐ Seizure disorder

Medications (attach MAF if in-school medication needed)

☐ Behavioral/mental health disorder

☐ Speech, hearing, or visual impairment

☐ None

☐ Yes (list below)

☐ Congenital or acquired heart disorder

☐ Tuberculosis

(latent infection or disease)

☐ Drugs (list) __________________________________________

☐ Developmental/learning problem

☐ Hospitalization

☐ Foods (list) __________________________________________

☐ Diabetes (attach MAF)

☐ Surgery

☐ Orthopedic injury/disability

☐ Other (specify)

☐ Other (list) __________________________________________

Explain all checked items above.

☐ Addendum attached.

Attach MAF if in-school medications needed

PHYSICAL EXAM

Date of Exam: ___ /___ /___

General Appearance:

Height

_____________ cm

( ___ ___ %ile)

☐ Physical Exam WNL

Abnl

Nl Abnl

Abnl

Nl Abnl

Weight

_____________ kg

( ___ ___ %ile)

☐ ☐ Psychosocial Development

☐ ☐ HEENT

☐ ☐ Lymph nodes

☐ ☐ Abdomen

☐ ☐ Skin

BMI

_____________ kg/m2

( ___ ___ %ile)

☐ ☐ Language

☐ ☐ Dental

☐ ☐ Lungs

☐ ☐ Genitourinary

☐ ☐ Neurological

Head Circumference (age ≤2 yrs)

_______ cm ( ___ ___ %ile)

☐ ☐ Behavioral

☐ ☐ Neck

☐ ☐ Cardiovascular

☐ ☐ Extremities

☐ ☐ Back/spine

Describe abnormalities:

Blood Pressure (age ≥3 yrs) _________

/ _________

DEVELOPMENTAL (age 0-6 yrs)

Nutrition

Hearing

Date Done

Results

Validated Screening Tool Used?

Date Screened

< 1 year ☐ Breastfed

☐ Formula ☐ Both

< 4 years: gross hearing

____/____/____

☐Nl

☐Abnl

☐Referred

☐ Yes

☐ No

____/____/____

≥ 1 year ☐ Well-balanced ☐ Needs guidance ☐ Counseled ☐ Referred

OAE

____/____/____

☐Nl

☐Abnl

☐Referred

Screening Results: ☐ WNL

Dietary Restrictions

☐ None ☐ Yes (list below)

≥ 4 yrs: pure tone audiometry

____/____/____

☐Nl

☐Abnl

☐Referred

☐ Delay or Concern Suspected/Confirmed (specify area(s) below):

Vision

Date Done

Results

☐ Cognitive/Problem Solving

☐ Adaptive/Self-Help

SCREENING TESTS

Date Done

Results

<3 years: Vision appears:

____/____/____

☐ Nl

☐ Abnl

☐ Communication/Language

☐ Gross Motor/Fine Motor

Blood Lead Level (BLL)

____ /____ /____

_________ µg/dL

Acuity (required for new entrants

Right _____ /_____

☐ Social-Emotional or

☐ Other Area of Concern:

(required at age 1 yr and 2

____ /____ /____

and children age 3-7 years)

____/____/____

Left

_____ /_____

Personal-Social

__________________________

yrs and for those at risk)

_________ µg/dL

☐ Unable to test

Describe Suspected Delay or Concern:

Lead Risk Assessment

____ /____ /____

☐ At risk (do BLL)

Screened with Glasses?

☐ Yes

☐ No

Strabismus?

☐ Yes

☐ No

(annually, age 6 mo-6 yrs)

☐ Not at risk

Dental

—— Child Care Only ——

__________ g/dL

Visible Tooth Decay

☐ Yes

☐ No

Hemoglobin or

____ /____ /____

Urgent need for dental referral (pain, swelling, infection)

☐ Yes

☐ No

Child Receives EI/CPSE/CSE services

☐ Yes ☐ No

Hematocrit

__________ %

Dental Visit within the past 12 months

☐ Yes

☐ No

CIR Number

Physician Confirmed History of Varicella Infection

Report only positive immunity:

IMMUNIZATIONS – DATES

IgG Titers

Date

DTP/DTaP/DT

____ /____ /____

Tdap

____ /____ /____

Hepatitis B

____ /____ /____

MMR

____ /____ /____

Measles

____ /____ /____

Polio

____ /____ /____

Varicella

____ /____ /____

Mumps

____ /____ /____

Hep B

____ /____ /____

Mening ACWY

____ /____ /____

Rubella

____ /____ /____

Hib

____ /____ /____

Hep A

____ /____ /____

Varicella

____ /____ /____

PCV

____ /____ /____

Rotavirus

____ /____ /____

Polio 1

____ /____ /____

Influenza

____ /____ /____

Mening B

____ /____ /____

Polio 2

____ /____ /____

HPV

____ /____ /____

Other

____ /____ /____

Polio 3

____ /____ /____

ASSESSMENT

Well Child (Z00.129)

Diagnoses/Problems (list)

ICD-10 Code

RECOMMENDATIONS

Full physical activity

☐Restrictions (specify) ____________________________________________________________________________

Follow-up Needed ☐ No	☐ Yes, for ___________________________			Appt. date: __ __ / ___ ___ / ___ ___
Referral(s): ☐ None	☐ Early Intervention	☐ IEP	☐ Dental	☐ Vision

☐Other ____________________________________________________________________________

Health Care Practitioner Signature

Date Form Completed

DOHMH

PRACTITIONER

_____ /_____ /_____

ONLY

I.D.

Health Care Practitioner Name and Degree (print)

Practitioner License No. and State

TYPE OF EXAM:

NAE Current

NAE Prior Year(s)

Comments:

Facility Name

National Provider Identifier (NPI)

Date Reviewed:

i.D. NUMBER

Address

City

State

Zip

______ / ______ / ______

reviewer:

Telephone

Fax

FORM ID#

CH205_Health_Exam_2016_June_2016.indd

⇩ PDF

Document Specifications

Fact Name	Description
Purpose of Form	The Child Adolescent Health Examination Form is used to gather health information about children and adolescents for school or camp enrollment in New York City.
Governing Body	This form is regulated by the New York City Department of Health and Mental Hygiene and the Department of Education.
Completion Requirement	It must be completed by a parent or guardian for students under 18 years old.
Medical History Section	The form includes a section for past or present medical conditions, including asthma, allergies, and developmental issues.
Physical Examination	A physical exam is required, during which height, weight, blood pressure, and other developmental assessments are documented.
Immunization Records	The form requests detailed immunization history, including vaccines administered and dates received for various illnesses.
Developmental Screening	It assesses various developmental domains such as communication, cognitive skills, and social-emotional growth.
Follow-Up Recommendations	Health care practitioners can provide recommendations for follow-up care based on their assessments and findings.
Signature Requirement	The form must be signed by a licensed health care practitioner as confirmation of examination and completion.

Steps to Filling Out Child Adolescent Health

Completing the Child Adolescent Health form is an important task that requires careful attention to detail. Each section of the form must be filled out accurately to ensure proper processing. Follow these steps to complete the form correctly and efficiently.

Gather Required Information: Collect your child's personal information, including their name, date of birth, and address. Also, have parents or guardians’ contact details ready.
Complete Personal Details: In the top section, write the child's last name, first name, middle name, sex, date of birth, and address accurately.
Select Ethnicity and Race: Indicate whether your child is Hispanic/Latino. Check all applicable race boxes.
Fill in School Information: Write the name of the school, center, or camp, and the district. Also, provide contact numbers for home and cell.
Insurance Information: Choose whether the child has health insurance and note if it includes Medicaid.
Complete Guardian Information: Enter the names and contact details of the parent or guardian, including email and work phone number.
Past Medical History Section: Indicate past or present medical conditions, allergies, and medications. Be as thorough as possible.
Physical Exam Information: Enter the date of the exam, and document height, weight, and blood pressure, if applicable.
Developmental Screening: Fill in results of hearing and vision tests. Provide information on dietary restrictions.
Immunization Dates: Record the dates for each immunization and any relevant titers.
Assessment and Recommendations: Tick if the child is a well child or list any diagnoses. Provide follow-up recommendations as needed.
Signature Section: The health care practitioner must sign and date the form. Include their name and license number.

Once you have completed the form, review it carefully to ensure all information is accurate. This form is crucial for your child's health assessment and needs to be submitted promptly to prevent any delays in care or services. Please ensure all relevant sections are completed and nothing is missed.

More About Child Adolescent Health

What is the purpose of the Child Adolescent Health form?

The Child Adolescent Health form is designed to gather comprehensive health information about children and adolescents. It aids health care practitioners in assessing a child's health status, identifying potential issues, and ensuring that appropriate support services are available. The form is useful for schools, camps, and other settings where child welfare is a priority.

Who needs to complete the Child Adolescent Health form?

The form should be completed by a parent or guardian of the child. This includes natural parents, step-parents, or legal guardians. Foster parents can also fill it out. Accurate and complete information is essential for proper assessment and care.

What information is required from parents or guardians?

Parents or guardians need to provide essential details like their child's name, date of birth, address, school, and contact information. They will also indicate the child's health insurance status, ethnicity, and any notable medical history. This foundation helps health care providers offer tailored care.

What medical history details are requested on the form?

The form asks about significant medical history, such as past conditions like asthma, diabetes, allergies, and psychiatric issues. It also requires information about any past surgeries, hospitalizations, and developmental or learning issues. Providing this information enables better health management and intervention when necessary.

How is the physical exam section structured?

The physical exam section allows health care practitioners to assess various aspects of a child's health, including general appearance, height and weight percentiles, and specific system checks (like lungs and cardiovascular health). This part helps to establish a baseline and identify any abnormalities.

What developmental screenings are included in the form?

Developmental screenings assess different areas of a child's growth, including nutrition, hearing, vision, and cognitive development. The form also checks for any immediate concerns or indicators that could lead to further evaluation. These screenings help ensure that children are developing at a healthy pace.

What immunization records need to be provided?

The form requires detailed immunization history, listing dates for various vaccinations like DTP, MMR, and Polio. This information is crucial to ensure that children receive all necessary immunizations for their age, helping to prevent the spread of infectious diseases in schools and communities.

What happens after the form is completed?

Once the form is filled out, it should be submitted to the designated health care practitioner or school authority. They will review the information, conduct a health examination, and may recommend further follow-up or referrals if needed. This process supports ongoing monitoring of the child's health.

Can the form be updated if the child's health status changes?

Yes, the form can and should be updated if there are significant changes in the child's health, such as new diagnoses, changes in medications, or new allergies. Keeping this information current is vital for ongoing health management and transparency with healthcare providers.

Where can parents or guardians obtain the Child Adolescent Health form?

The Child Adolescent Health form is usually available through schools, health care providers, and the NYC Department of Health and Mental Hygiene. You can also download the form from official health department websites. Be sure to use the latest version for the most accurate and relevant information.

Common mistakes

Inconsistent Information: Ensure that all details, such as the child's name and date of birth, are consistent across forms. Incorrect or differing information may lead to confusion or processing delays.
Incomplete Sections: Fill out every applicable section completely. Missing information can hinder the evaluation of the child’s health and may require additional follow-up.
Neglecting Required Attachments: It's essential to attach any necessary Medical Authorization Forms (MAF) when in-school medications are indicated. Omitting these can delay necessary medical care.
Using Inaccurate Medical Histories: Providing inaccurate or outdated information regarding the child’s past medical history may result in inappropriate recommendations or treatment plans. Always verify details before submission.
Failure to Indicate Allergies: If the child has any allergies, especially to medications, they must be clearly indicated on the form. This information is crucial to avoid potential health risks.
Improper Signature: Ensure that the appropriate guardian or parent signs the form. A missing or incorrect signature can render the form invalid, causing disruptions in care.

Documents used along the form

When addressing a child's health needs, there are several important forms and documents that complement the Child Adolescent Health form. Each of these documents plays a vital role in gathering relevant information about a child's overall well-being. Below is a list of such forms, along with a brief description of their purpose.

Consent for Treatment Form: This document allows a parent or guardian to authorize health care providers to give necessary medical treatment to their child. It ensures that caregivers can act swiftly in emergencies.
Immunization Record: This form tracks all vaccines a child has received. Keeping a detailed record is essential for school enrollment and preventing outbreaks of vaccine-preventable diseases.
Medication Administration Form (MAF): When a child requires medication during school hours, this form must be completed. It provides vital information about dosages and times, ensuring medications are administered safely.
Vision and Hearing Screening Report: This document records the results of a child's vision and hearing assessments. Early detection of issues can lead to timely intervention, promoting better developmental outcomes.
Physical Assessment Form: A comprehensive evaluation of a child’s physical health. It includes height, weight, and other critical measurements to assess growth and development.
Health History Questionnaire: Parents or guardians complete this form detailing the child’s past medical issues, allergies, and family health history. This background helps health care providers build an accurate picture of the child's health.
Emergency Contact Information: This form lists individuals to contact in case of an emergency. Having accurate and up-to-date information is crucial for swift communication during critical moments.

These forms collectively contribute to a holistic understanding of a child's health needs. They ensure that health care providers have the information necessary to deliver safe and effective care. Taking the time to complete these documents is a crucial step in supporting a child’s health journey.

Similar forms

The Child and Adolescent Health Examination Form shares similarities with the School Health Form, often required by educational institutions. Both documents gather essential information regarding a child’s health history, demographic information, and any existing medical conditions. Parents or guardians complete similar sections regarding the child's name, birth date, and pertinent medical history, ensuring a comprehensive understanding of each child's health needs as they enter or participate in school programs.

Another comparable document is the Well Child Visit form. This form focuses specifically on routine health checkups for children. Like the Child and Adolescent Health Examination Form, it includes sections for vaccination records, developmental milestones, and any ongoing health issues. The goal is to track the child's growth and health status over time, providing a similar overview of health conditions and necessary follow-ups.

The Immunization Record is also akin to the Child and Adolescent Health Examination Form. Both collect information on a child's vaccination history, ensuring that essential immunizations are up to date. This document plays a vital role in protecting public health, much like the examination form, which assures that children are monitored for their immunization status during health assessments.

The Behavioral Health Assessment form mirrors the Child and Adolescent Health Examination Form in that both documents address mental and emotional wellbeing. Each form typically includes screening questions for behavioral health issues and information regarding any past or present mental health conditions. This allows healthcare providers to assess and address both physical and mental health aspects in children.

The Consent for Treatment form can also be viewed as similar. Parents or guardians complete this document, granting permission for their child to receive medical attention. This is important for both addressing immediate health concerns and ensuring that any ongoing treatments align with the health information gathered in the Child and Adolescent Health Examination Form, fostering a cohesive approach to care.

Additionally, the Physical Examination Report is another document with similarities. It provides an overview of the child's physical health, much like the examination form. It includes vital signs, growth measurements, and results from various screenings. Both forms serve to create comprehensive medical records, facilitating informed decision-making for future healthcare needs.

The Special Education Eligibility form aligns closely, especially when detailing developmental or learning delays. It requires information about the child's overall health and developmental status, similar to the comprehensive evaluations found in the Child and Adolescent Health Examination Form. Both documents play a role in determining the services a child may need to thrive in an educational setting.

Lastly, the Annual Health Assessment form for camps and recreational programs addresses similar aspects. It collects data related to a child's medical history, immunizations, and health screenings, aiming to ensure safety and preparedness in group settings. Much like the Child and Adolescent Health Examination Form, it ensures that children participating in these activities are healthy and fit for their environments.

Dos and Don'ts

Do's:

Print the child's name clearly in the designated fields.
Include accurate contact information for the parent or guardian.
Provide detailed medical history, marking all relevant conditions.
Ensure all sections are completed, especially regarding immunizations.

Don'ts:

Do not use abbreviations or shorthand when writing the information.
Avoid leaving any required fields blank, as this could delay processing.
Do not provide inaccurate information, particularly about health conditions.
Refrain from omitting past medical treatments or significant allergies.

Misconceptions

Misconception 1: Only children with health issues need to fill out the Child Adolescent Health form.

This form is essential for all children and adolescents, regardless of their current health status. It provides a comprehensive overview that helps healthcare providers ensure well-rounded care.

Misconception 2: The form is just for school entry.

While it is often required for school enrollment, the form is also used for camps, sports, and other activities. It ensures that all caregivers are aware of the child's health needs.

Misconception 3: Parents should fill out the form without any guidance from healthcare professionals.

Parents are encouraged to consult with healthcare providers when completing the form. This collaborative approach ensures accuracy and completeness in the child's health history.

Misconception 4: The Child Adolescent Health form is too lengthy to be important.

Despite its length, every section plays a crucial role in assessing a child's health and development. The information helps create tailored health plans and interventions.

Misconception 5: Completing the form guarantees immediate healthcare access.

While the form is vital for establishing health records, it does not automatically guarantee immediate access to healthcare services. Other factors may still influence appointment availability and care access.

Key takeaways

The Child Adolescent Health form plays a crucial role in gathering important health information for children and adolescents. Here are key takeaways for effectively completing and utilizing the form:

Print Clearly: It is essential to fill out the form using clear and legible handwriting to ensure accurate information entry.
Accurate Personal Information: Verify that the child's last name, first name, and middle name are filled out correctly.
Demographic Details: Include the child’s date of birth, address, and school information, as this helps in identifying the child accurately.
Insurance Status: Indicate whether the child has health insurance or if the individual is a foster parent.
Medical History Section: Detail any past or present medical conditions carefully. It is vital for healthcare practitioners to understand the child’s health history.
Allergies: List any known allergies along with prescribed medications like Epi pens, if applicable.
Behavioral Concerns: Include any behavioral or mental health disorders, as this helps providers offer tailored care.
Screening Tests: Record the results of any hearing or vision tests performed, ensuring to specify if any referral is needed.
Vaccination Records: Document all immunization dates accurately. This is important for maintaining proper health records.
Signature Required: Ensure that the healthcare practitioner signs and dates the form to validate the information provided.

Following these guidelines enhances the utility of the Child Adolescent Health form, which in turn supports the health and well-being of the child.