RITE CHOICE EARLY LEARNING CHILD CARE, LLC

CHILD & ADOLESCENT HEALTH EXAMINATION FORM

NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION

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Print Clearly

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Child’s Last Name First Name Middle Name

Child’s Address

City/Borough State Zip Code

Parent/Guardian Last Name First Name

Foster Parent
School/Center/Camp Name

Sex
Female

Male
Hispanic/Latino?

Yes No
Race
(Check ALL that apply) American Indian Asian Black White

Native Hawaiian/Pacific Islander Other ____________________________
PHYSICAL EXAMINATION

Height ____________________

Weight ____________________

BMI ____________________

Head Circumference

Blood Pressure
cm ( ___ ___ %ile)kg ( ___ ___ %ile)kg/m2 ( ___ ___ %ile)(age ≤2 yrs) ______________ cm ( ___ ___ %ile)(age ≥3 yrs) _________ / __________
DEVELOPMENTAL

If delay suspected, specify below
(age 0-6 yrs) Within normal limits

Cognitive (e.g., play skills) ____________________________

Communication/Language _________________________

Social/Emotional __________________________________

Adaptive/Self-Help ________________________________

Motor ___________________________________________
SCREENING TESTS
Date Done Results
Blood Lead Level (BLL)
__ __ / ___ ___ / ___ ___ _________ μg/dL
(required at age 1 yr and 2 yrs

and for those at risk)
__ __ / ___ ___ / ___ ___ _________ μg/dL
Lead Risk Assessment

(annually, age 6 mo-6 yrs)
At risk (do BLL)
__ __ / ___ ___ / ___ ___
Not at risk
Hearing

Pure tone audiometry Normal

OAE __ __ / ___ ___ / ___ ___ Abnormal
—— Head Start Only ——

Hemoglobin or
__________ g/dL
Hematocrit
(age 9–12 mo)
__ __ / ___ ___ / ___ ___
__________ %
Date Done Results

Tuberculosis

who have not previously attended any NYC public or private school
Only required for students entering intermediate/middle/junior or high school
PPD/Mantoux

PPD/Mantoux

Interferon Test

Chest x-ray
placed __ __ / ___ ___ / ___ ___ Induration ______mmread __ __ / ___ ___ / ___ ___ Neg Pos__ __ / ___ ___ / ___ ___ Neg PosNl Not
(if PPD or Interferon positive)

__ __ / ___ ___ / ___ ___

Abnl Indicated
Vision

__ __ / ___ ___ / ___ ___

Acuity
Right ___ / ___
(required for new school entrants Left
___ / ___
and children age 4–7 yrs)
with glasses Strabismus No Yes
General Appearance:

Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl

HEENT Lymph nodes Abdomen Skin Psychosocial Development

Dental Lungs Genitourinary Neurological Language

Neck Cardiovascular Extremities Back/spine Behavioral
Date of Birth

__ __ / ___ ___ / ___ ___ ___ ___
(Month/Day/Year )
Phone Numbers

Home
_____________________
Cell
______________________
Work
______________________
TO BE COMPLETED BY PARENT OR GUARDIAN

TO BE COMPLETED BY HEALTH CARE PROVIDER
If “yes” to any item, please explain (attach addendum, if needed)
CH-205 (5/08)
Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian
Medications
(attach MAF if in-school medication needed)

None Yes (list below)
Dietary Restrictions

None Yes (list below)
Influenza
__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
MMR
__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Varicella
__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Td
__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Tdap
__ __ / ___ ___ / ___ ___ Hep A __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Meningococcal
__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
HPV
__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Other,
specify: ____________ __ __ / ___ ___ / ___ ___ ; _______________ __ __ / ___ ___ / ___ ___
IMMUNIZATIONS – DATES

of Child
CIR Number
Describe abnormalities:

District __ __

Number __ __ __