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GEMINUS HEAD START/EARLY HEAD START PHYSICAL EXAMINATION Child’s Name: Birth date Sex : Age: ____________________________________________________________ _____/_____/_______ ______ _____ Head Start Early Head Start Height: ___________ Weight : _____________ BMI: ____________ B/P: (EPSDT requirement for children 3 or over) ________________ Head Circumference (0 – 24 months only) __________ *Lead Level: Date _____/______/________ Result ______________ *Hemoglobin: Date _____/_____/________ Result ___________ *Head Start requires proof of 9 month and 24 month old lead and hemoglobin screenings or child must be screened Add’l work (to be done at physician’s discretion ) EXAMINATION NORMAL Sickle Cell : Date __________ Result _______ ABNORMAL COMMENTS Head Eyes Nose Throat Chest Mouth/Dental Cardiovascular/HTN TB Test: Date __________ Result___________ Is the child receiving treatment for any of the following conditions? Condition Yes No Anemia High Lead Levels Overweight Underweight Does Child Wear Glasses If ‘Yes’ to any above questions, what is treatment plan? Respiratory Endocrine Genito-Urinary Neurological Musculoskeletal Spinal Exam Nutritional status Sleep Habits Self Help Skills Mental Health Hearing and Vision Screening R L Code: Vision Speech Motor Cognitive Social Has child ever been hospitalized or operated on? Hearing If ‘Yes’ to the following questions, please provide Comments ______ Yes ______ No Has child ever had a serious accident (broken bones, head injuries, falls, burns, poisoning)? _____ Yes _______ No Has child ever had a serious illiness? ______Yes _______ No Is child currently being treated by a physician? ______ Yes _______ No Is child taking medications at this time? _______ Yes _______ No Does child have any physical limitations that prevent full participation, including outdoor activity? _______ Yes _______No Page 1 of 2 P = Pass F = Fail U = Unable to test R = Referred GEMINUS HEAD START/EARLY HEAD START PHYSICAL EXAMINATION QUESTIONS Does child have: Asthma (If yes, please complete and attach Follow-up Care Plan) Allergies (If yes, please complete and attach a Follow-up Care Plan) Diabetes (If yes, please complete and attach a Follow-up Care Plan) Seizures (If yes, please complete and attach a Follow-up Care Plan) Bee sting allergy (If yes, please complete and attach a Follow-up Care Plan) Other ____________________ (If yes, please complete and attach a Follow-up Care Plan) Yes No Immunization record (1) (2) (3) (4) (5) DTAP _______________ _____________ _____________ ______________ ______________ Polio _______________ _____________ ______________ ______________ MMR _______________ _____________ HIB _______________ _____________ ______________ ______________ HepB _______________ _____________ ______________ ______________ PCV _______________ _____________ _____________ ______________ Varicella __________ _____________ Other ________________________________________________________ *Hep B #4 required if #3 was given before 24 weeks. Please Print or Stamp Physician’s Name: ____________________________________________________ Address: ___________________________________________________________ Phone: ____________________________________________________________ Fax: _______________________________________________________________ ____________________________________________________ _____________ Physician’s Signature Date Page 2 of 2 Geminus Head Start 8400 Louisiana St. Merrillville, IN 46410 1-888-893-6891 Head Start – Early Head Start Oral Health Form Patient Information ( For age eligible Children or Pregnant Mother) Name Date of birth Is the dental practice completing exam the dental home of patient?: Yes No Current Oral Health Status Does the child have any teeth with untreated decay? Yes (decay) No (decay free) Does the child have any teeth that have previously been treated for decay, including fillings, crowns, or extractions? Yes No Are there treatment needs? Yes, urgent Yes, not urgent No treatment needs Oral Health Care Services Delivered During Visit Diagnostic/Preventive Services Examination: Yes No X-rays: Yes No Risk assessment: Yes No Cleaning: Yes No Fluoride varnish: Yes No Dental sealants: Yes No Counseling/Anticipatory Guidance Yes No Referral to Specialty Care Yes No Restorative/Emergency Care Fillings: Yes No Crowns: Yes No Extractions: Yes No Emergency care: Yes No Other: (Please specify specialist) (Please specify) Future Oral Health Care Services All treatment completed: Yes No More appointments needed for treatment? Next recall date: Yes / (month/year) No If yes: Approximate number of appointments needed: Next appointment: Date: Time: Additional Information for Parents, Head Start Staff, and Medical Providers Oral Health Provider’s Contact Information and Signature Provider name (please print) n Phone number Practice name nAddress Provider signature nDate of service n Fax number This document was prepared under grant #9OHC0005 for the U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start, by the National Center on Health. This publication is in the public domain, and no copyright can be claimed by persons or organizations.
