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ATSI CHILD HEALTH ASSESSMENT AGE 0-14YRS ITEM 715 Patient’s Name: <PtFirstName> Sex: <PtSex> Current Contact Details Phone: <PtPhoneH> Address:<PtAddress> DOB: <PtDoB> Age: <PtAge> (Please tick box) Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Mother’s Name: Mother’s DOB: Patient Consent/Parent or Carer consent Explanation of health check given Patient/ parent/carer consent for health check Date consent was given: Would you like a written copy of the health check and recommendations for you and your child? Yes No Previous Health Check Has the patient had a previous health check? Yes No Date of last health check (if known) (must be more than 9 months ago) Alternative Contact Details Phone: Address: Consent given for information to be collected by GP Practice Nurse Health Worker Other please specify Details of GP conducting this health check: MEDICAL HISTORY CURRENT HEALTH PROBLEMS/ ISSUES PAST MEDICAL HISTORY, HOSPITALISATIONS AND INJURIES <PMHAll> ALLERGIES/ DRUG INTOLERANCES <Reactions> CURRENT MEDICATIONS (including prescription and over the counter ) <CurrentRx> RELEVANT FAMILY MEDICAL HISTORY <FamilyHx> IMMUNISATION STATUS Check Blue Book (or if details unavailable and child less than 7 years can check with ACIR) Note: Catch-up Calculator - http://www.health.sa.gov.au/immunisationcalculator Age due Birth 2 months 4 months 6 months 12 months 18 months 2 years 4 years Year 8 at school SA Immunisation Schedule for ATSI children Hep B Hib/Hep B Prevenar Infanrix/IPV Hib/Hep B Prevenar Infanrix/IPV Prevenar Infanrix/IPV Hib/Hep B MMR Men C Varicella Hep A Pneumovax 23 Hep A MMR Infanrix/IPV Boostrix (dTpa) Varicella (if not given before or no history of chicken pox) Hep B (if dod not receive primary course) Other immunisations Type Date received Date ANY CONCERNS ABOUT HEARING? HISTORY OF NEONATAL SCREEN? HISTORY OF OTHER SCREENING? ANY CONCERNS ABOUT VISION? PHYSICAL ACTIVITY- Detail Any Concerns? NUTRITION Any Concerns? EDUCATIONAL PROGRESS Any Concerns? DEVELOPMENT Any concerns identified by parent /carer / teacher / child? No Yes, Details: RELEVANT SOCIAL HISTORY/ HOUSING Who does the child live with? Who is the primary carer of the child? What is the current housing situation? How many people live in the house? Any concerns of overcrowding? Does anyone in the household smoke? If so, do they want assistance to quit? Does the mother/ primary carer need help or support with alcohol, gambling, cigarettes, drug use? STRESSFUL LIFE EVENTS: HISTORY RELEVANT TO SPECIFIC AGE GROUPS INFANT RELEVANT NOTES: (Write N/A if not relevant) Mother’s pregnancy Any complications during pregnancy? Where did you attend antenatal care? Any issues with the health care? Birth and neonatal period Mode of Delivery Gestation Birth weight Any complications during or shortly after the delivery? Breast feeding/ Bottle feeding Weaning, food access and dietary history Any questions or concerns? Physical activity (details) Vision and hearing (including neonatal hearing screening) Development (achievement of age-appropriate milestones) Assess risk factors for SIDS Provide education Do you have any concerns about your infant? Review of Blue Book Any issues not covered? Mother’s/ primary carer’s current well being (support network, stressors/mood, general health, DV) History of Newborn Check? Dietary details of typical day Personal-Social (e.g. smile, plays, indicates wants) Concerns? Yes No Fine Motor- Adaptive (e.g. grasps rattle, pincer grasp, tower of cubes) Concerns? Yes No Language (e.g.. Laughs, turns to voice, speech, words) Concerns? Yes No Gross Motor (e.g.. Rolls over, sits, stands, walks, jumps, balance) Concerns? Yes No Yes No/uncertain If less than 2 years old and no/uncertain, for full newborn examination. CHILD IN ADOLESCENT STAGE (eg. age 12-14) ALCOHOL (if applicable) Identified issues Action SMOKING/ TOBACCO (if applicable) Identified issues Action OTHER SUBSTANCE USE (if applicable) Identified issues Action Ask about mood, depression/anxiety, self-harm and general well-being Identified issues Action SEXUAL AND REPRODUCTIVE HEALTH (if applicable) Sexually Active? Risk of STIs? Contraception? Identified issues Action OTHER HISTORY CONSIDERED NECESSARY LIVING CONDITIONS AND EXPOSURE TO ENVIRONMENTAL FACTORS Physical Activity Nutrition MEDICAL EXAMINATION WEIGHT: kg ( %ile) Identified issues HEIGHT: cm ( %ile) BMI Action VISUAL ACUITY (red reflex in newborn) Left: Right: Normal Abnormal Bilateral: Identified issues EAR AND HEARING: Otoscopy Normal Action Abnormal Whisper test Normal Abnormal Referral for Tympanometry and Audiology? Yes No Identified issues Action GUMS AND DENTITION Normal Abnormal (Dental hygiene and access to dental services) Identified issues SKIN Action (skin sores etc) Identified issues Action New Born Baby Check – if not previously completed Identified issues Action CARDIAC AUSCULTATION (consider congenital heart disease/rheumatic heart disease) abnormality detected Abnormal Identified issues RESPIRATORY EXAMINATION No abnormality detected Identified issues ABDOMINAL EXAMINATION No abnormality detected Abnormal TRICHIASIS Trachoma check if indicated Action Abnormal Action No Identified issues Action ASSESSMENT OF PARENT CHILD INTERACTION Identified issues Action OBSERVED INTERACTION BETWEEN PARENT/CARER AND CHILD (if indicated) OTHER EXAMINATIONS CONSIDERED NECESSARY BY GP Examination Identified problems INVESTIGATIONS AS REQUIRED Investigation Arrange FBC testing for children at high risk of anaemia Arrange urinalysis Audiometry conducted when required and at, or just before, school entry? BSL ? Tests done Tests ordered Date: Arrangements (e.g. referral details) Date: Date: Date: Date: Date: SUMMARY ASSESSMENT OF PATIENT (based on consideration of evidence from patient history, examination and results of any investigation) EXISTING HEALTH PROBLEMS or IDENTIFIED ISSUES ARE ANY OF THESE INTERVENTIONS REQUIRED? Treatment Follow-up Immunisation Referral Medical INTERVENTION ACTION/ RECOMMENDATIONS Yes, Today Yes, organised for when? No / Not necessary Dental Home visiting program referral Family-focused intervention Liaison with the patient's school and other service provider Advice on: Physical activity/ Exercise Diet and nutrition Parenting Sun protection Injury prevention Infant issues: Breast/ bottle feeding SIDS prevention Support for Mother Adolescent issues: Substance use (including tobacco) prevention and treatment Safe sex advice Other interventions?