COMPREHENSIVE HEALTH AND
DEVELOPMENT ASSESSMENT
0 - 11 YEARS	FROM <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

COMPLETE ALL 6 FIELD TABS, then go back to
COMPLETE THE **HEALTH MANAGEMENT PLAN**
<<Health Management Plan must be completed>>
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 and 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:
<<Clinical Details:Family History>>
<<Clinical Details:Social History>>
<<Clinical Details:Past Obstetric History>>
	
MEDICAL HISTORY e.g. hospital admissions, diagnoses, NDIS, known mental health diagnosis: 
<<Clinical Details:History List>>

Allergies: <<Clinical Details:Allergies/Adverse Reactions>>
	
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 - 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/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/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 Activty>>

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

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

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

Comments: <<Measurements: Any comment?>>
	
GENERAL APPEARANCE: <<General Appearance>>

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

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, e.g. 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.	
<<Summary:Investigation Results (Selected)>>

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 <<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 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 share with Child Safety?>>
•	<<Health assessment shared with Nurse Navigator?>>
•	<<Health assessment shared with My Health Record?>>
•	<<Health assessment shared with other Health Profls?>> <<If other Health Professionals, please specify>>