Kindergarten Health Check · Web viewThis procedure provides a standard approach for nurses when...

CHHS17/015

Canberra Hospital and Health ServicesClinical ProcedureKindergarten Health CheckContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alert.......................................................................................................................................... 3

Scope........................................................................................................................................ 3

Section 1 – Process for Kindergarten Health Check..................................................................3

1.1 Eligible Clients.................................................................................................................3

1.2 Consent...........................................................................................................................4

1.3 Preparation prior to KHC.................................................................................................4

1.4 Nurses roles and responsibilities.....................................................................................5

1.5 Kindergarten ‘Catch Up’ and ‘Hearing Retest’ clinics......................................................6

Section 2 – Anthropometric Measurements.............................................................................7

2.1 Procedure to measure Weight........................................................................................7

2.2 Procedure to measure Height.........................................................................................7

2.3 Calculation of Body Mass Index (BMI).............................................................................7

2.4 Referral Pathway.............................................................................................................8

Section 3 – Vision Check Procedure..........................................................................................8

3.1 Procedure........................................................................................................................8

3.2 Document results as follows:........................................................................................10

3.3 Referral Criteria.............................................................................................................10

Section 4 – Hearing Check Procedure.....................................................................................11

4.1 Procedures....................................................................................................................11

4.2 Hearing Referrals Guide................................................................................................12

4.3 Hearing Retest Clinic.....................................................................................................12

Implementation...................................................................................................................... 13

Related Policies, Procedures, Guidelines and Legislation.......................................................13

References.............................................................................................................................. 13

Search Terms.......................................................................................................................... 14

Attachments............................................................................................................................14

Doc Number Version Issued Review Date Area Responsible PageCHHS17/015 1 14/02/2017 01/02/2022 WY&C 1 of 22

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Attachment 1: Flowcharts and Q drive location of KHC forms and letters..........................15

Attachment 2: Height, Weight & Body Mass Index (BMI) Measurements..........................19

Attachment 3: Snoring and Your Child................................................................................21



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Purpose

This procedure provides a standard approach for nurses when performing Kindergarten Health Check’s (KHC) in government and non - government schools in the ACT.

The KHC is a primary health care service that aims to identify potential health issues associated with weight, vision and hearing. Early intervention and appropriate referral/s may optimise the child’s learning, social development and general health outcomes.

Back to Table of Contents

Alert

Kindergarten Health Check Records are confidential. The records are not to be left in the school, government cars or taken home. They are to come back to the central office and be placed in a lockable filing cabinet.

The KHC must not proceed without parental/guardian consent.


Scope

This document applies to nurses who work in the Women Youth and Children’s Community Health Programs (WYCCHP), School Health Team and deliver the KHC.


Section 1 – Process for Kindergarten Health Check

1.1 Eligible ClientsKindergarten students in the ACT will be offered a school health check at their school of enrolment. A parent or guardian must sign consent for this service, which is provided free of charge.

All children in kindergarten in ACT are offered a health check during the first year of formal education (kindergarten or equivalent school program).

Children exempt from the program include Jervis Bay Primary School students, and Cranleigh or Malkara Special school program

1.2 ConsentAt the start of the school year parents or guardians of Kindergarten students will receive the KHC Consent and Questionnaire Form (See attachment 1.2). Parents or guardians are



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required to sign the consent form for the KHC to proceed. Parent or guardian consent is also required for the student’s teacher to be informed of vision and/or hearing results.

Parents or guardians who have nominated a General Practitioner (GP) or Medical Practice are also consenting for the results of the physical health check and the Parents’ Evaluation of Developmental Status (PEDS) and Strengths and Difficulties Questionnaire (SDQ) results to be sent to that Medical Practice. The GP may then contact the parents/guardians to discuss the results and refer to appropriate services as necessary.

The 1st section of the KHC Consent and Questionnaire Form questions relate specifically to the physical health check, conducted by the School Health Team.

The 2nd section of the form includes the PEDS, SDQ and questions relating to Asthma, Allergies, Parent’s perception of their child’s weight/height, Physical Activity and Nutrition. The Academic Unit of General Practice (AUGP) and Population Health collect data from both sections of the questionnaire for research and health service planning. The AUGP is responsible for the management of the 2nd section of the KHC Consent and Questionnaire, including scoring the PEDS & SDQ and collating the questionnaires.

Parents will receive in a package with the KHC Consent and Questionnaire, a letter of explanation ‘Information for the Kindergarten Health Check’ and ACT Health Promotion materials, as well as an envelope in which to return the completed questionnaire to school.

1.2.1 Parent or Guardian Request for Copy of Health Check ResultsA copy of the completed KHC Clinical Record is sent to the nominated GP after the health check. A parent/guardian requesting a copy of the KHC Clinical Record will be directed to ACT Health Clinical Records Department or alternatively, can consult with the GP about results.

1.3 Preparation prior to KHCThe School Health Team and AUGP work together in the preparation and processing of the KHC and work with primary schools to implement the program.

The school principals receive a letter of explanation prior to the KHC and a request is made for the principal to nominate a school contact person. The principal is also sent an ‘Environmental Safety checklist’ of minimum requirements for the School Health Team to conduct a safe, effective and efficient health service.

At the start of each school year the KHC Nurse Co-ordinator contacts all the school KHC contact people/school office and schedules/confirms dates for the KHC for that year.

The KHC Nurse Co-ordinator liaises with AUGP Research Nurse and School Health Team Administration Officers (ASOs) to develop a calendar for KHC paperwork pickup from the AUGP to School Health Team office. The calendar enables a manageable distribution of KHC paperwork for processing between the AUGP and the School Health Team.



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A flow chart that outlines the responsibilities of the KHC processing between the AUGP and School Health Team is reviewed and updated annually

1.3.1 Paperwork organisation prior to KHCThe School Health Team will: Check calendar for schools scheduled for KHC Remove school to be processed from KHC filing cabinets Gather handouts including Dental Brochure, Nutrition – ‘Tuck a Talk’, Information about

Height, Weight and Body Mass Index (See attachment 2) and other handouts relevant to parental concerns such as incontinence management and Your Child and Snoring (See attachment 3)

On each child’s paper work check; The child’s details match including name, date of birth, addresss, phone contact on KHC

Consent and Questionnaire Form, KHC Results Summary, and Parents Results Letter (See attachment 1.2, 1.3, 1.4)

Check parental consent for KHC has been ticked YES Check if consent for hearing and vision results has been ticked YES, to share with the

relevant teacher If there is a NO consent for the hearing and vision results to be given to the Teacher,

ensure this is highlighted on KHC Results Summary, and that it is also highlighted on the class list

If there is no parental consent, please consult with the KHC Co-ordinator Check in the KHC Consent and Questionnaire Form for any parental concerns regarding

vision and hearing If there are any parental concerns write them on the front of the KHC Results Summary

above the results area for Vision Acuity and Hearing Check for parental concerns regarding Snoring (See attachment 3) and Incontinence. It

the parent has ticked YES to any of the above, or has mentioned asthma, include the relevant handout in the parent paperwork, and TICK the corresponding box on the front of the KHC Results Summary

Once all classes from the school have been processed, return school batch to KHC filing cabinet.

1.4 Nurses roles and responsibilitiesNurses will be responsible for; Checking the environment is suitable to conduct health check as per Staff Environment

Checklist for Kindergarten Health Check (See attachment 1.8) Notifying the Manager/ Central CNC if there are any concerns with the venue

or implementing health check activitieso Taking the equipment, student files to the schoolo Transporting student files in a confidential satchel o Checking that all equipment is either available or in the car e.g. scales,

audiometer, vision box and stadiometer/portable height measureo Collecting school mobile phone/devices



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o Completing KHC Results Summary (See attachment 1.3)o Completing ‘Parent Results Letter‘ (See attachment 1.4) ready for posting at

completion of KHC o Contacting parents / guardians, where necessary with results of KHCo Providing Kindergarten teachers with the vision & hearing results of children of

consenting parents/ guardians o Ticking the relevant box on the Results Summary if the parent/guardian has been

contactedo Restocking the documentation, paperwork and handouts.

1.4.1 Documentation Nurses to check the forms for consent, parental concerns and child’s history prior to

health check Health check results, recommendations, referrals and handouts enclosed with results to

recorded in KHC Results Summary (see attachment 1.3) Parents Results Letter (See attachment 1.4) is completed with appropriate referrals and

handouts A second nurse rechecks the BMI calculation, referral/s and health promotion

information before posting to parent/guardian The Parent Results Letter (see attachment 1.4) and health promotion handouts are

placed in envelopes ready to be posted Teachers Results Sheet (See attachment 1.5) identified concerns for hearing and/or

vision only of students with parental consent for teacher to be informed Absent Letter (See attachment 1.1) is posted to parent’s postal address with the offer of

a catch up KHC appointment.

1.4.2. On Return to Base File KHC Results Summary by school name in strict alphabetical order Photocopy KHC Results Summary of students who require hearing retest and referral

then file under Hearing Retest, in filing cabinet File the Results Summary paperwork of students who were absent or have moved

interstate and file under ‘Absent’, in filing cabinet Prepare/restock equipment, documentation, handouts and files for next day.

1.5 Kindergarten ‘Catch Up’ and ‘Hearing Retest’ clinicsAppointments for ‘Catch Up’ clinic and ‘Hearing Retest clinics are made through Community Health Intake (CHI) 6207 9977 KHC ‘Catch Up’ appointments are for children who were absent at school on the day of

the KHC, or for parents/carers that prefer to be present during the check (30 minute appointments)

KHC Hearing Retest clinics are for kindergarten children who did not reach the ‘normal’ hearing level threshold (15 minute appointments)

Kindergarten Health Check ‘catch up’ clinics are scheduled according to demand and in a centrally located health centre.



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Section 2 – Anthropometric Measurements

Nurses will adhere to ‘Hand Hygiene and Infection Control’ measures as per the Healthcare Associated Infections Clinical Guideline.

Height, Weight and Body Mass Index2.1 Procedure to measure Weight Digital scales are annually calibrated and are for use on hard level surface Ask the child to remove shoes, jumper and /or jacket Ensure digital scales are reading zero Ask the child to stand on centre of scale Record the weight in KHC Results Summary (See attachment 1.3) Results to be kept confidential from child and other children.

2.2 Procedure to measure Height Use a stadiometer (or height rule) with attached headboard Ask the child to remove shoes and hair ornaments Ask the child to stand with back to stadiometer, stand straight so that their heels,

buttocks and shoulders are in contact with the measuring rod. The heels should also be touching each other and arms by the sides. The child should look straight ahead. Ask the child to take a deep breath and stand tall before taking the measurement.

Lower the headboard to lightly rest on the child’s head and bend to child’s height for accurate record

Record the height to the nearest 0.1cm in KHC Results Summary (see attachment 1.3) Results to be kept confidential from child and other children.

2.3 Calculation of Body Mass Index (BMI)2.3.1 Calculate BMI using Electronic DeviceCalculate BMI with electronic device using Centre for Disease Control (CDC) children’s BMI calculator at https://nccd.cdc.gov/dnpabmi/calculator.aspx



https://nccd.cdc.gov/dnpabmi/calculator.aspx

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2.3.2 Calculate BMI with calculator and BMI index percentile charts

Formula: BMI = Weight (kg)(Height X Height)

Example: Weight: 18.2 kg, Height: 108.3BMI = 18.2 BMI= 18.2

(1.083 x 1.083) 117.2BMI = 15.52

Use CDC ‘BMI-for-Age Percentile Chart’ to plot BMI result, according to gender and age.

2.4 Referral Pathway Document results on KHC Results Summary (see attachment 1.3) BMI Results that are outside the “Healthy Weight” range, it is recommended that

parent/guardian see their GP and/or dietitian A nurse will phone the parent if there are significant weight concerns, guided by clinical

judgement and/or following discussion with Kindergarten Co-ordinator or CNC. Refer to BMI referral flow chart for KHC (see attachment 1.6) as a guide.

Alert: BMI percentiles are a guide only and are not diagnostic of weight status categories but contribute to the overall clinical impression (Government of Western Australia, 2014).


Section 3 – Vision Check Procedure

3.1 ProcedureSelect a quiet area free from distractions as per Staff Environment Checklist for Kindergarten Health Check (See attachment 1.8) Check if parent has any concerns with child’s vision Observe child’s general appearance, head posture, evidence of eye infection Avoid glare in the child’s eyes

3.1.1 Equipment required for vision screening Pen torch 3 metre measure Vision box (3 metre) and light remote control Stycar- 7 letter card Eye patch Fixation stick



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3.1.2 Vision Screening Procedures – Sequence of EventsExplain the procedure in age appropriate termsa. Corneal Light Reflexes

o Hold torch level with child’s eyes, about 30cm from faceo Observe position of the corneal light reflection in either eye

b. Cover/ Uncover Testso One eye is occluded with nurse’s hand taking care not to touch the child’s faceo The nurse observes for any movement in the child’s uncovered eye whilst fixing the

child’s attention on a near objecto As the eye is uncovered the nurse watches for any movement

c. Ocular Movementso Hold stick about 30cms from child’s faceo Watch the child’s eyes to see if they have moved to fix on targeto Continue to observe the child’s eyes to see if fix is maintainedo To confirm fixation, the target can be moved slightly and the child’s eyes observed

for correctional fixation movements

d. Trackingo Hold stick about 30cms from the child’s faceo Move the stick in either the following pattern below, observing the child’s

movements at all times for any deviation o Ensure the child’s head remains still and they are not turning their head towards the

fixation stick. You may place your hand under the child’s chin to stabilise the head.o Repeat the cover test looking at an object 6 metres away (if environment amenable)

(note: either methods are acceptable)

e. ConvergenceHold fixation stick at forearm distance from the child, move the stick at a steady pace towards the child’s nose and observe for equal convergence of both eyes



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f. Visual Acuity (Stycar 7 letters)o Sit the child 3 metres from the vision chart ensuring the distance is accurateo Ask the child to hold the vision card on their lap and question the child about the

name of the letters. If the child’s responses are not reliable, introduce it as a ‘matching game’

o Always test the right eye first to avoid errors in recording.o Point to the letters from below, ensuring the pointer does not obstruct the letters

Start at the top of the chart and move down quickly, only 1-2 letters per line until the 3/3 line

Ask the child to read the entire line If the child is unsure, go back up a line and have the child read the whole line and come back down

The child does not pass the line if 2 or more letters are incorrectly named or matched

The child passes the line if all letters are correctly read or matched.1(-1) letter variance is acceptable.

o Record the vision results for the right eye before repeating the process for the left eye

o Children who wear glasses should be tested with their glasses on, it is not necessary to test without glasses.

o Results recorded in the KHC Results Summary.

3.2 Document results as follows:Testing distance (3m) / Level of accurate vision achieved R) 3/3 or L) 3/3 = Normal 3/3 -1 = Normal 3/ 4.5 > 6 years = Refer 3/ 4.5 < 6 years = Retest when over 6 years Unequal vision acuity results = Refer 3/6 + = Refer Movement, tracking, convergence irregularities = Refer

3.3 Referral Criteria Provide parent with Parent Results Letter and School Health Team referral (white original

& pink). Green referral copy is attached to KHC Results Summary. The parent needs to contact Community health Intake (CHI) for Orthoptist appointment

Referral options include Orthoptists, Optometrist or GP for further assessment and management

Retest at Optometrist A nurse will phone the parent if there are significant vision concerns, guided by clinical

judgement and/or following discussion with Kindergarten Co-ordinator or CNC




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Section 4 – Hearing Check Procedure

4.1 ProceduresSelect a quiet area free from distractions: as per Staff Environment Checklist for Kindergarten Health Check (See attachment 1.8) Turn the audiometer on for 10 minutes and check for normal function Explain the procedure in age appropriate terms Give clear instructions to the child to listen for ‘beep’ or ‘buzz’ sounds and to respond by

clapping their hands Seat the child in a comfortable position so that the child’s hands can be clearly seen by

the nurse Assist child to remove glasses, clips and place hair behind their ears Prior to placing the headphones on the child, conduct a trial test by presenting a few

signals at different frequencies and demonstrating the correct response. Ensure the volume is turned down to no higher than 60dBs before testing with headphones.

Face the child front on and place the headphones, red to right and blue to left ear Ensure the headphones are comfortable and covering the ear completely Test the right ear first unless there is a known hearing loss, in which case start with the

better hearing ear The sequence for testing is 1000 Hertz (Hz), 2000Hz, 4000Hz then 500Hz. Begin testing at 40 decibels (dBs) and press tone/pulse button for up to 2 seconds Decrease by 10dBs, at varying and irregular intervals, until 20dBs is reached Two out of three positive responses at 20dBs must be achieved at each frequency for

hearing to be within normal limits. If the child is unable to get two out of three responses at 20dBs, it is documented at the

dB level where two out of three positive responses occurred at the frequency tested. The child will be referred for a hearing retest or Audiometry Clinic (See below for Hearing Pathway Referral)

Repeat same procedure for the left ear Record results on KHC Results Summary (see attachment 1.3)

The dB level is recorded over the frequency leveli.e. Normal Hearing is recorded as;

Right: 20/500 20/1000 20/2000 20/4000 Left: 20/500 20/1000 20/2000 20/4000

Indicate in the Right column of the KHC Results Summary, if the hearing isNormal Hearing or Hearing Retest Clinic or Audiometry Referral

A nurse will phone the parent if there are significant hearing concerns, guided by clinical judgement and/or following discussion with Kindergarten Co-ordinator or CNC. Hearing Referral Pathway Flowchart (See attachment 1.7).

4.1.1 Assist children to understand instruction



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There may be some 5-6 year olds who have difficulty understanding the instructions for a hearing check.

These are some useful strategies to help them: Present the sounds at a louder frequency and role model the response Switch ears to see if you can get a response.

4.2 Hearing Referrals GuideFollow referral pathway if retest or referral is required:Hearing Retest:For students who respond; 25 - 30dBs at 500 Hzand/ or 25 dBs at any other frequency

(i.e.1000, 2000 and 4000 Hz)and No parental concerns

If the child has a cold, it is preferable that there is a minimum gap of 4 weeks between screening and hearing retest.

Refer to Audiometry Nurse: For students who respond;

35dBs (or more) at 500Hzand/or 30 dBs (or more) at any other frequency

(i.e. 1000, 2000 and 4000Hzs) Screening not passedand Parent or nurse concerns and/or Language, speech concerns

Record on : KHC Results SummaryParent Results LetterTeacher Results Form (if parent/guardian consented)

See Hearing Referral Pathway Flowchart (See attachment 1.7)

4.3 Hearing Retest Clinic Audiometry hearing screen is repeated in a centrally located Health Centre. Students who do not PASS at 20dBs across frequencies (i.e. 1000, 2000, 4000and 500Hzs)

are referred to the Audiometry Clinic. The Nurse completes the ‘Hearing Retest’ form and attaches to the student’s KHC Clinical

Record. The parent is given a form that ‘denotes’ the results as ‘Normal Hearing’ or Audiometry

Clinic referral. The form provides information about booking appointment at the Audiometry Clinic through CHI.



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Implementation

This procedure will be incorporated into training of new staff at orientation and will be referenced in the annual credentialing of clinical skills for all nurses working in the School Health Team, in particular vision and hearing screening techniques.

The document will be communicated in clinical team meeting and referred to as the framework for clinical discussion for the Kindergarten Health Check.


Related Policies, Procedures, Guidelines and Legislation

Policies Consent and Treatment Policy CHHS Patient Identification and Procedure Matching Policy Incident Management Policy Work Health and Safety policy

Procedures and Guidelines Australian Audiometry Nurse Association Clinical Standards, 2015 CHHS Healthcare Associated Infections, CHHS 15/072 Clinical Records, Records Management Manual DGD12-048 Paediatric Anthropometric Measurements

Legislation ACT Government Occupational Health and Safety Act 1989 Health Records (Privacy and Access) Act 1997


References

1 Commonwealth of Australia, 2009 National Children’s Vision Screening Project Final Report, accessed 2nd October 2012http://www.rch.org.au/emplibrary/ccch/Vision Screening Final Report May 2009.pdf

2 Community Health Manual Procedure, School aged children, Govt of Western Australia, department of Health, 2014

3 Early Childhood Vision Screening School of Applied Vision Sciences Faculty of Health Sciences University of Sydney, 2003

4 Martin, F.N. and Clark, J.D. 2000. Pure-Tone Audiometry. In Martin, F.N. and Clark, J.D. Introduction to Audiology, 7th Ed. Chapter 4, pages 73-8



http://www.rch.org.au/emplibrary/ccch/Vision

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5 National Centre for Health Statistics, 2000. Centres for Disease Control and prevention growth charts USA accessed from http://www.cdc.gov/growthcharts/ May 2016

6 NHMRC Endorsed 15 March 2002. Child Health Screening and Surveillance. A Critical Review of the Evidence. Report prepared by the Centre for Community health, Royal Children’s Hospital Melbourne for the NHMRC. pp 88-105.

7 NHMRC 2010. Management of overweight and obesity in adults, adolescents and children in Australia, pp 81 - 99.


Search Terms

Body Mass Index, Children, Community, Kindergarten Health Check, Paediatrics, School Screening, School Vision, School Hearing, Surveillance


Attachments

Attachment 1: Q drive location of KHC forms and lettersAttachment 2: Parent information handout

‘Height, weight & BMI (Body Mass Index)’Attachment 3: Parent information handout

‘Snoring and your Child’

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



http://www.cdc.gov/growthcharts/

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Attachment 1: Flowcharts and Q drive location of KHC forms and letters

1. Absent Letter Q:\CH\CY&W\CY&W_General\RegionalTeams\Central\School Health Team\School Imm.& Kindys\Immunisation and Kindy 20--\Kindy 20--\LettersandHandouts

2. KHC Consent and Questionnaire FormQ:\CH\CY&W\CY&W_General\RegionalTeams\Central\School Health Team\School Imm.& Kindys\Immunisation and Kindy 20--

3. KHC Results Summary Q:\CH\CY&W\CY&W_General\RegionalTeams\Central\School Health Team\School Imm.& Kindys\Immunisation and Kindy 20--\Kindy 20--\LettersandHandouts

4. KHC Parent Results LetterQ:\CH\CY&W\CY&W_General\RegionalTeams\Central\School Health Team\School Imm.& Kindys\Immunisation and Kindy 20--\Kindy 20--\Letters andHandouts

5. Teachers Results SheetQ:\CH\CY&W\CY&W_General\RegionalTeams\Central\School Health Team\School Imm.& Kindys\Immunisation and Kindy 20—



C:\\Users\\Erin cronin\\AppData\\Local\\Microsoft\\Windows\\Temporary Internet Files\\Content.Outlook\\ITQZW03J\\Kindergarten Health Check clinical document.doc






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6. BMI referral flow chart for KHCQ:\CH\CY&W\CY&W_General\RegionalTeams\Central\School Health Team\School Imm.& Kindys\Immunisation and Kindy 20—\kindy\dates



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7. Hearing Referral Pathway Flowchart Q:\CH\CY&W\CY&W_General\RegionalTeams\Central\School Health Team\School Imm.& Kindys\Clinical



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8. Staff Environment Checklist for Kindergarten Health checkQ:\CH\CY&W\CY&W_General\RegionalTeams\Central\School Health Team\School Imm.& Kindys\Immunisation and Kindy 20—

School: ............................................... Date: …………………………………………...Name: ……………………………………………. Signed: .............................................

Date Checked: Requirements meet

Requirements Yes No

Parking to be as close as possible to the room the nurses will be using for the Kindergarten Health Check

The Rooms for Kindergarten Health Check

Two rooms are required one for vision and one for hearing; they need to be in close proximity to each other and close to the Kindergarten classroom

The nurses will need exclusive use of the room/s while at the school to carry out the health checks and be able to secure the room when unattended

To carry out the vision testing they require a distance of 3 meters this area must allow for uninterrupted viewing/matching of letters by the child and be free of distractions to ensure accurate testing

The room/area to carry out the hearing testing must be quiet enough to allow for the nurses to test hearing that will give accurate results

The room should provide adequate lighting and heating/cooling as appropriate

2 -3 tables of a good working height for adults

4 adult sized chairs for the nurses. This is a Work Safety requirement to reduce the risk of injury

Hand washing facilities nearby

Need to be easy access to power points in both rooms for the hearing and vision equipment

Staff aware of emergency exits, Fire Extinguishers & Evacuation Assembly Points





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Attachment 2: Height, Weight & Body Mass Index (BMI) MeasurementsAccessed from the Policy Register (http://inhealth/PPR/default.aspx)



http://inhealth/PPR/default.aspx

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Attachment 3: Snoring and Your ChildAccessed from the Policy Register (http://inhealth/PPR/default.aspx)



http://inhealth/PPR/default.aspx

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