COMPREHENSIVE HEALTH AND DEVELOPMENT ASSESSMENT
>12 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: <Does pt identify as Aboriginal/Torres Strait Islander>
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 young person, e.g. to healthcare providers, Child Safety? <Consent given for sharing of information>	
Gillick competent? <Gillick competent>	

Refer to Supporting Health History, e.g. 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 - is further action required?>
	
PRESENTING CONCERNS e.g. carer concerns and young person's main worry e.g. behaviour, sleep, school attendance
<Presenting concerns>
	
HEEADSSS	
HOME
Where are they living currently, who else lives there, how long have they been living there, have the had adverse experiences while living there, do they feel safe?
<Home>

Home - further action required?  <Home - further action required>
	
EDUCATION OR EMPLOYMENT
Where, problems, bullying, academic achievement or grades, protective relations with peers or teacher/supervisor, career goals, known neurodevelopmental diagnosis or learning issues including intellectual impairment?
<Eudcation or employment>

Education or employment - further action required?  <Education or employment - further action required>
	
EATING / EXERCISE
Nutrition, vegan/vegetarian, weight gain/loss, physical activity, fitness, preoccupation with weight/body image, any restricting/purging/supplements?
<Eating / exercise>

Eating/exercise - further action required?  <Eating/exercise - further action required>
	
ACTIVITIES/ PEERS
Hobbies, belonging to a peer group, peer activities, involvement in organised sport/religion etc, risk taking, managing chronic illness, injury, avoidance, screen time
<Activities/Peers>

Activities/Peers - further action required?  <Activity/peers - further action required>
	
DRUG & ALCOHOL USE
Smoking, alcohol and illicit drug use, prescription drug use, inhalants, frequency, consequences
<SmkStatus>
<AlcHx>

<Drug and Alcohol>

Drug & Alcohol - further action required?  <Drug and Alcohol - further action required>

SEXUALITY & GENDER
Contraception, consent, level of knowledge, sexually active, age of onset, safe sex practices, same sex attraction, sexual identity, STI screening, unwanted sex/sexual abuse?
<Sexuality and Gender>

Sexuality & Gender - further action required? <Sexuality and Gender - further action required>
	
SUICIDE & MENTAL HEALTH
Depressed mood, anxiety Sx, sleep disturbances, self-harm, suicidal ideation/intention/method/past attempts, MSE?
<Suicide and Mental Health>

Suicide & Mental Health - further action required? <Suicide and Mental Health - further action required?>
	
SAFETY / SPIRITUALITY
Bullying, abuse, traumatic experiences, risky behaviour, belief, religion, what gives them a sense of meaning?
<Safety / Spirituality>

Safety/Spirituality - further action required? <Safety/Spirituality - further action required>

EXAMINATION	
Height (cm): <Height (cm)>	<Height - normal/abnormal>	Comment: 	
Weight (kg): <Weight>	<Weight - normal/abnormal>	Comment:	
BMI: <BMI>	<BMI - normal/abnormal>	Comment: 	
BRIEF SYSTEMS REVIEW	
GENERAL APPEARANCE, including skin
<General Appearance, including skin>

General Appearance - further action required? <General Appearance - further action required>
	
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>
	
EAR, NOSE & THROAT, e.g. otoscopy, tonsils, nasal polyps
<Ear, Nose and Throat>

Ear, nose & throat - normal/abnormal? <Ear, nose and throat - normal/abnormal>
	
VISION
<Vision>

Vision - normal/abnormal? <Vision- normal/abnormal>
	
CARDIAC heart rate and rhythm, BP and cardiac auscultation
<Cardiac>

Cardiac - normal/abnormal? <Cardiac - normal/abnormal>
	
RESPIRATION EXAMINATION
<Respiration examination>

Respiration examination - normal/abnormal?  <Respiration - normal/abnormal>
	
CHEST EXAMINATION
<Chest examination>

Chest examination- normal/abnormal?  <Chest examination - normal/abnormal>
	
NEUROLOGICAL EXAMINATION
<Neurological Examination>

Neurological examination - normal/abnormal?  <Neurological examination - normal/abnormal>
	
GAIT & SPINAL EXAMINATION Musculoskeletal structure, balance, condition
<Gait and spinal examination>

Gait & spinal examination - normal/abnormal?  <Gait and spinal examination - normal/abnormal>
	
SIGNS OF PUBERTY Tanner stage (self reported)
<Signs of puberty - Tanner stage (self reported)>

Signs of puberty - normal/abnormal?  <Signs of puberty - normal/abnormal>
	
GYNAECOLOGICAL EXAM if required - early CST
<Gynaecological Exam if required>

Gynaecological exam - normal/abnormal?  <Gynaecological exam - 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	
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>