Physical Form

UNIVERSAL CHILD HEALTH RECORD

Endorsed by:

American Academy of Pediatrics New Jersey Department of New Jersey Academy of

New Jersey Chapter Health and Senior Services Family Physicians

SECTION I - TO BE COMPLETED BY PARENT(S)

Child’s Name (Last) (First)

Gender

Male Female

Date of Birth

/ /

Parent/Guardian Name

Home Telephone Number

Work Telephone/Cell Phone Number

Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number

I give my consent for my child’s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form.

Signature/Date

This form may be released to WIC.

Yes No

SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDER

Date of Physical Examination: Results of physical examination normal? Yes No
Weight(must be taken within 30 days for WIC)

Height (must be taken within 30 days for WIC)

Head Circumference

(if <2 Years)

Blood Pressure

(if >3 Years)

IMMUNIZATIONS

Immunization Record Attached

Date Next Immunization Due:

MEDICAL CONDITIONS

Chronic Medical Conditions/Related Surgeries

· List medical conditions/ongoing surgical concerns:

None

Special Care Plan Attached

Comments

Medications/Treatments

· List medications/treatments:

None

Special Care Plan Attached

Comments

Limitations to Physical Activity

· List limitations/special considerations:

None

Special Care Plan Attached

Comments

Special Equipment Needs

· List items necessary for daily activities

None

Special Care Plan Attached

Comments

Allergies/Sensitivities

· List allergies:

None

Special Care Plan Attached

Comments

Special Diet/Vitamin & Mineral Supplements

· List dietary specifications:

None

Special Care Plan Attached

Comments

Behavioral Issues/Mental Health Diagnosis

· List behavioral/mental health issues/concerns:

None

Special Care Plan Attached

Comments

Emergency Plans

· List emergency plan that might be needed and the sign/symptoms to watch for:

None

Special Care Plan Attached

Comments

PREVENTIVE HEALTH SCREENINGS

Type Screening

Date Performed

Record Value

Type Screening

Date Performed

Note if Abnormal

Hgb/Hct

Hearing

Lead: Capillary Venous

Vision

TB (mm of Induration)

Dental

Other:

Developmental

Other:

Scoliosis

Name of Health Care Provider (Print)

Signature/Date


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