PRELIMINARY HEALTH CHECK	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

Assessment date <TodaysDate>

Patient details	

RE: <PtFullName>

DOB: <PtDoB>
Age at time of assessment: <PtAge>
Assigned Sex: <PtSex>
Gender: <GenderIdentity>	Ethnicity: <PtEthnicity>
Cultural & linguistic diversity other than A&TSI: <Cultural & linguistic diversity other than A&TSI>	

Child's Legal Guardian/s
<Child's Legal Guardian - name & contact details>	

Other Key Stakeholders (NDIS/ECEI/Child Safety)
<Key Stakeholder Services, contacts and details>	

Does this child have a My Health Record? <Does this child have a My Health Record>	
Confidentiality Statement provided? <Confidentiality Statement provided>	
Consent given for sharing of information in the best interests of the child/young person, e.g. to healthcare providers, Child Safety? <Consent given for sharing of information>	

Refer to Supporting Health History, e.g. Red Book, information from Child Safety	
PRESENTING CONCERNS e.g. carer concerns and child's main worry:
<Presenting concerns>
	
MEDICATIONS
<CurrentRx>

Over the counter, alternative medications:
<Over the counter, alternative medications>
	
IMMUNISATIONS HISTORY, e.g. AIR records, check for multiple Medicare numbers
<Imm>

Immunisation - is further action required? <Immunisation - is further action required>	

EXAMINATION	
Height (cm): <Height (cm)>	<Height - normal/abnormal>	Comment: 	
Weight (kg): <Weight>	<Weight - normal/abnormal>	Comment:	
BMI (plot on growth chart): <BMI>	<BMI - normal/abnormal>	Comment: 	
Temperature: <Temperature>	<Temperature - normal/abnormal>	Comment: 	
Head circumference (cm): <Head circumference (cm)>	<Head circumference - normal/abnormal>	Comment: 	
Examination findings:
<Examination findings>
	
LEARNING AND DEVELOPMENT (speech/language incl, hearing, gross motor, fine motor, social, cognitive) e.g. early childhood education/school attendance, developmental milestones, known neurodevelopmental diagnosis or learning issue, intellectual impairment:
<Learning and Development>

Is learning and development normal/abnormal? <Learning and development - normal/abnormal>	
ANY OTHER OBSERVED CONCERNS e.g. developmental, social, practitioner concerns:
<Any other observed concerns>

Are other observed concerns normal/abnormal? <Any other observed concerns - normal/abnormal>
	
Date for Comprehensive Health and Developmental Assessment: <Health and Development Assessment Date>

Book long appointment and review the local Health Pathway prior e.g. children and young people in care, child development	

PERSON COMPLETING PRELIMINARY HEALTH CHECK	
Clinical Name <DrName>	
Practice <Practice>	
Provider Number <DrProviderNo>	
Time taken to complete health check (minutes) <Time taken to complete health check (minutes)>	
Date for review <Date for review>	
PLEASE CONSIDER THE PRIVACY OBLIGATIONS FOR SECURE SENDING OF HEALTH INFORMATION
This Preliminary Health Check has been shared (in the best interests of the child/young person) with:
• <Preliminary Health Check shared with parent?>
• <Preliminary Health Check shared with carer?>
• <Preliminary Health Check shared with Child Safety?>
• <Preliminary Health Check shared with Nurse Navigator?>
• <Preliminary Health Check shared with My Health Record?>
• <Preliminary Health Check shared with other Health Professionals?>  <If other Health Professionals, please specify>