Head Start capk PX form

Community Action Partnership of Kern Head Start / State Child Development CHILD HEALTH RECORD PHYSICAL EXAMINATION/SCREENINGS/ASSESSMENT CHILD’S NAME:____________________________________________________ SEX:__________ BIRTHDATE:________________________ HEAD START CENTER:_________________________________________________ PHONE:_______________________________________ 1. RELEVANT INFORMATION (from Health History, Parent/Teacher Observations): SCREENING TEST. Starred items (*) are required by Head Start and recommended by the American Academy of Pediatrics for children 3-5 years Enter dates if done previously. Please provide numerical results. 2. TEST DATE RESULTS TEST DATE RESULTS ______Yrs. _____Mos. a. * PRESENT AGE *i. VISION (Type of Test) Comments: b. HEIGHT (no shoes __________________________ Comments: to nearest 1/8” in.) ACUITY: R________________ L_________________ c. WEIGHT (light clothing to STRABISMUS ______________ nearest ¼ lb.) *j. HEARING (Type of Test) d. * HEAD CIRCUMFERENCE __________________________ (age two (2) and under) Results: L _____________ e. * HEMATOCRIT or R _____________ HEMOGLOBIN k. OTHER TESTS (if indicated) Comments: f. * LEAD g. * BLOOD PRESSURE Given: (1) Sickle Cell _ Read: (2) Ova & Parasites h. * TUBERCULOSIS (TB) Negative _______ (3) Urinalysis Positive________ (4) Other 3. PHYSICAL EXAMINATION/ASSESMENT: complete NORMAL ABNORMAL - NOT COMMENTS (Use Additional sheet if necessary) FOR AGE EVALUATED GENERAL APPEARANCE POSTURE, GAIT SPEECH HEAD SKIN EYES: (1) External Aspects (2) Optic Fundiscopic (3) Cover Test EARS: (1) External & Canals (2) Tympanic Membranes NOSE, MOUTH, PHARYNX TEETH HEART LUNGS ABDOMEN (include hernia) BONES, JOINTS, MUSCLES NEUROLOGICAL/SOCIAL (1) Gross Motor_________________ (2) Fine Motor___________________ (3) Communication Skills_________ (4) Cognitive____________________ (5) Self-Help Skills_______________ (6) Social Skills__________________ GENITALIA Date:_______________________ GLANDS OTHER _______________________________ MUSCULAR COORDINATION GENERAL STATEMENT ON CHILD'S PHYSICAL STATUS Signature: 4. FINDINGS, TREATMENTS, AND RECOMMENDATIONS: Abnormal Findings/Diagnosis Treatment Plan Recommended Follow-up or Result (initial Date when complete) a. 7/2014 b. c. d.