UNIVERSALCHILD HEALTH RECORD

Endorsed by: 0'

American Academy of Pedlatrics,New JerseY-ChapterNew Jersey Academy 9,( F~f[llIy PhysiciansNew Jersey Department of'Health and Senior Servicas

Does Child Have Health Insurance?DYes ONo

Gendero Male 0 Female

If Yes, Name of Child's Health Insurance Carrier

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

Home Telephone NumberParent/Guardian Name 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 IThis fonm may be released to WIC.

DYes DNo

Date of Physical Examination:Abnormalities Noted:

Results of physical examination normal?

Weight(must be takenwithin 30 days for WIC)

Height (must be takenwithin 30 days for WlC)Head Circumference(if <2 Years)Blood Pressure(if ~3 Years)

IMMUNIZATIONSDlmmunization RecordAttachedDOate Next Immunization Due: __

MEDICAL CONDITIONSChronic Medical Conditions/Related Surgeries• List medical conditionslongoing surgical

concems:

DNone I CommentsDSpecial Care Plan

Attached

MedicationslTreatments• List medicationsltreatments:

DNone .OSpecial Care PlanAttached

Comments

Limitations to Physical Activity• List limitations/special considerations:

DNoneOSpecial Care Plan

Attached

Comments

·CommentsSpecial Equipment Needs• . List items necessary for daily activities

ONoneOSpecial Care Plan .

AttachedCommentsAllergies/Sensitivities

• List allergies:

DNoneOSpeclal Care Plan

Attached

Special OieWitamin & Mineral Supplements• List dietary specifications:

CommentsDNoneOSpecial Care Plan

AttachedBehavioral Issues/Mental Health Diagnosis• List behavioral/mental health

issues/concerns:

ONoneOSpecial Care PlanAttached

Comments

Emergency PlansList emergency plan that might be neededand the sion/svrnotoms to watch for:

~ I IHearingDate Performed I Record Value I Type ScreeningType Screening

ONoneOSpecial Care Plan

Attached

Comments

PREVENTIVE HEALTH SCREENINGSDate Performed Note if Abnormal

Hgb/Hct.Lead: OCapillary DVenous Vision

T8 (mm of Induration) Dental

Other:ScoliosisDevelopmental

Other:Name of Health Care Provider (Print) Heaith Care Provider Stamp:

Signature/Date