Head Start Well Child Examination Form - Minnesota Valley Action Counsil
ADVERTISEMENT
1Head Start
Well Child Examination
Patient Information
Child’s
Gender
Date of
Male
Female
Name
Birth
Measurement
Height
Weight
Body Mass Index
Blood Pressure
Pulse
Date of exam
%
%
%
Child Health History
Laboratory (Lead)
Chronic Medical Conditions:
Require verification of a prior blood lead screening result. If none
available – draw today.
Record
Date
Allergies:
Lead
Value
Record
Date
Medications:
Hgb/Hct (if ordered)
Value
Behavioral/Mental Health Disorder:
Immunizations
MN Law requires children (3-5) enrolling in an Early Childhood
Physical Examination
Program have received a minimum:
N=Normal AB=abnormal
N
Ab
Document abnormals
3-Hep B; 4-DTaP; 3-Polio; 1-MMR; 1-Hib; 1-Varicella; 1-Hep A
by number:
1.
General Appearance
Please check the box that applies
2.
Skin
Child has completed immunizations required by MN
3.
Nodes
law.
4.
Head
Behind on immunization schedule. Must receive all
5.
Eyes
required immunizations within 18 months of initial
6.
Ears
enrollment. Plan to receive them is: (imms. & dates?)
7.
Nose
8.
Mouth
9.
Neck
Child has a medical contraindication or HX of disease
10. Chest
with laboratory evidence of adequate immunity that
11. CV
exempts them from the immunization(s) listed below.
12. Abd
13. Genitourinary
14. Musculo-Skeletal
Varicella: Disease was medically diagnoses or
15. Neuro
adequately described to provider that varicella
infection occurred in:
Developmental/S-E/Mental Health
(year)
Developmental Screening
____________________________________________________________________________________________
N
Ab
Parent conscientiously opposed to immunization(s).
Tool used?
No
Personal/Social
(HS will inform parent of additional paperwork
Yes
requirements)
Name of tool:
Cognitive
Immunizations ordered/given today:
Social-emotional Screening
Speech/language
DTaP
Varicella
IPV/OPV
Hep A
Tool Used?
No
Fine Motor
Hib
Hep B
MMR
Yes
Name of tool:
Gross Motor
Concerns:
Assessment
Additional diagnosis (specify)
Child Well
Hearing Screening
Vision Screening
Visual Acuity screened using an
Screened using pure tone
LEA/HOTV chart or screening
audiometer or OAE?
No
Machine?
No
Yes, results are:
Yes, results are:
Follow-up and Referrals
Pass
Pass
Rescreen in ______________
Rescreen in ____________
Refer
Refer
Concerns:
Concerns:
As legal guardian of this child I authorize the health care provider to release the above requested information to MVAC Head Start for the
purpose of providing care to my child and supporting my family in obtaining any indicated follow-up care and/or needed treatment.
_________
______________________________________________
____________________________________________
__________
Date
Parent signature
Date
Health Care Provider Signature
______________________________________________________
_________________________________________________________
Printed Name
Printed Name
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical