PRELIMINARY HEALTH CHECK	FROM <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

Assessment Date: <<Miscellaneous:Date (long)>>

Patient details

RE: <<Patient Demographics:Full Name>>

DOB: <<Patient Demographics:DOB>> 
Age at time of assessment: <<Patient Demographics:Age>>
Assigned sex: <<Patient Demographics:Sex>>
Gender: <<Gender>>	A&TSI: <<Patient Demographics:ATSI>>
Other cultural and linguistic diversity: <<Cultural and 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. 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 
<<Clinical Details:Medication List>>

Over the counter, alternative medications: 
<<Over the counter, alternative medications>>

IMMUNISATION HISTORY e.g. AIR records, check for multiple Medicare numbers
<<Clinical Details:Immunisation List>>

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

EXAMINATION	
Measurements: <<Clinical Details:Measurements (Selected)>>

Head circumference (cm): <<Head circumference (cm)>>

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

Comments: <<Measurements - any comments?>>
	
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 Development Assessment: <<Health & 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 <<Doctor:Name>>     Date: <<Miscellaneous:Date (long)>>	
Practice: <<Practice:Name>>	
Provider Number: <<Doctor:Provider Number>>	
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 check shared with Nurse Navigator?>>
•	<<Preliminary check shared with My Health Record?>>
•	<<Preliminary check shared with other Health Profls?>> <<If other Health Professionals, please specify>>