COMPREHENSIVE HEALTH AND DEVELOPMENT ASSESSMENT
0 - 11 YEARS	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

COMPLETE ALL FIELD TABS, then go back to
COMPLETE THE **HEALTH MANAGEMENT PLAN**

Assessment Date: <TodaysDate>

Patient details	

RE: <PtFullName>

DOB: <PtDoB>
Age at time of assessment: <PtAge>
Assigned Sex: <PtSex>
Gender: <Gender>	Ethnicity: <PtEthnicity>
Other cultural and linguistic diversity: <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, 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	
BIRTH AND FAMILY HISTORY, e.g. prematurity, alcohol/drug use in pregnancy, time in special care unit, mental health and hereditary conditions:
<FamilyHx>
<SocialHx>
<ObstetricHx>
<ObstetricHxFull>	
MEDICAL HISTORY e.g. hospital admissions, diagnoses, NDIS, known mental health diagnosis:
<PMHAll>

Allergies: <Reactions>
	
MEDICATIONS
<CurrentRx>

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

Immunisation - is further action required? <Immunisation - further action required?>
	
PRESENTING CONCERNS e.g. carer concerns and young person's main worry e.g. behaviour, sleep, school attendance
<Presenting concerns>
	
EMOTIONAL WELLBEING e.g. mental health, trauma, use "Strengths & Difficulties Questionnaire"
<Emotional Wellbeing>

Emotional Wellbeing - further action required? <Emotional Wellbeing - further action required>
	
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>

Learning and Development - further action required? <Learning and Development - further action required?>
	
SEXUAL HEALTH & BEHAVIOURS e.g. sexualised behaviour, menarche and details of cycle, sexual activity, contraception:
<Sexual Health and Behaviours>

Sexual Health & Behaviours - further action required? <Sexual Health and Behaviours - further action required>
	
HEALTHY EATING e.g. nutrition milk, transition to solids, appetite, range of foods eaten:
<Healthy Eating>

Healthy Eating - further action required? <Healthy Eating - further action required>
	
PHYSICAL ACTIVITY
<Physical Activity>

Physical Activity - further action required? <Physical Activity - further action required>
	
BLADDER & BOWEL e.g. toilet training, enuresis/nocturnal enuresis, constipation, encopresis:
<Bladder and Bowel>

Bladder & Bowel - further action required? <Bladder and Bowel - 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: 	
Head circumference (cm): <Head circumference (cm)>	<Head circumference - normal/abnormal>	Comment: 	
GENERAL APPEARANCE:
<General Appearance>

General Appearance - further action required? <General Appearance - further action required>
	
HEAD e.g. fontanelles, sutures, plagiocephaly
<Head e.g. fontanelles, sutures, plagiocephaly>

Head - further action required? <Head - further action required>
	
VISION	
Left Eye		Right Eye		
Appearance	<Vision/Left Eye - Appearance>	Appearance	<Vision/Right Eye - Appearance>	
Red Reflex	<Vision/Left Eye - Red Reflex>	Red Reflex	<Vision/Right Eye - Red Reflex>	
Fixation/cover text	<Vision/Left Eye - Fixation/cover text>	Fixation/cover text	<Vision/Right Eye - Fixation/cover text>	
HEARING	
Left Ear		Right Ear		
Appearance	<Hearing/Left Ear - Appearance>	Appearance	<Hearing/Right Ear - Appearance>	
Otoscopy	<Hearing/Left Ear - Otoscopy>	Otoscopy	<Hearing/Right Ear - Otoscopy>	
Audiometry	<Hearing/Left Ear - Audiometry>	Audiometry	<Hearing/Right Ear - Audiometry>	
Tympanometry: <Tympanometry>	
SPEECH & LANGUAGE
<Speech and Language>

Speech & Language - normal/abnormal? <Speech and Language - normal/abnormal>
	
ORAL & DENTAL HEALTH, e.g. last dental check, tonsils
<Oral and Dental Health>

Oral & Dental Health - normal/abnormal? <Oral and Dental Health - normal/abnormal>
	
CVS
HR: <CVS - HR>
Sounds: <CVS - Sounds>
Rhythm: <CVS - Rhythm>
Femoral pulses: <CVS - Femoral pulses>
Brachial pulses: <CVS - Brachial pulses>

CVS - normal/abnormal? <CVS - normal/abnormal>
	
RESPIRATORY
RR: <Respiratory - RR>
Sounds: <Respiratory - Sounds>

Respiratory - normal/abnormal? <Respiratory - normal/abnormal>
	
ABDOMINAL EXAMINATION
<Abdominal examination>

Abdominal examination - normal/abnormal? <Abdominal examination - normal/abnormal>
	
GENITALIA (only for baby check)
<Genitalia (only for baby check)>

Genitalia - normal/abnormal?  <Genitalia - normal/abnormal>
	
ANUS (only for baby check)
<Anus (only for baby check)>

Anus - normal/abnormal?  <Anus - normal/abnormal>
	
HIPS
<Hips>

Hips - normal/abnormal?  <Hips - normal/abnormal>
	
UPPER LIMBS
<Upper limbs>

Upper limbs - normal/abnormal?  <Upper limbs - normal/abnormal>
	
LOWER LIMBS
<Lower limbs>

Lower limbs - normal/abnormal?  <Lower limbs - normal/abnormal>
	
NEUROLOGICAL EXAMINATION - age specific: gait, tone, power, reflexes, sensation
<Neurological examination - age specific>

Neurological Examination - normal/abnormal?  <Neurological Examination - normal/abnormal>
	
SPINE
<Spine>

Spine - normal/abnormal?  <Spine - normal/abnormal>
	
ANY OTHER OBSERVED CONCERNS, e.g. developmental, social, practitioner concerns
<Any other observed concerns, eg developmental>

Any other observed concerns - normal/abnormal?  <Any other observed concerns - normal/abnormal>

INVESTIGATIONS Please consider accessing results available via The Viewer or private pathology/radiology companies & My Health Record	
<Ix>

Investigations - normal/abnormal?  <Investigations - normal/abnormal>

**HEALTH MANAGEMENT PLAN FOR EARLY INTERVENTION e.g. GPMP, GPMHP, NDIS, ECEI	
Issues/goals	Actions taken	By whom e.g. GP, carer, patient, Child Safety	

			

PERSON COMPLETING ASSESSMENT	
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 Health Assessment has been shared (in the best interests of the child/young person) with:
• <Health Assessment shared with parent?>
• <Health Assessment shared with carer?>
• <Health Assessment shared with Child Safety?>
• <Health Assessment shared with Nurse Navigator?>
• <Health Assessment shared with My Health Record?>
• <Health Assessment shared with other Health Professionals?>  <If other Health Professionals, please specify>