COMPREHENSIVE HEALTH AND
DEVELOPMENT ASSESSMENT
>12 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 fields 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>>
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 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:
<<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 information required? <<Immunistion - further information 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 they 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?
<<Education 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? <<Activities/peers - further action required>>
	
DRUG & ALCOHOL USE
Smoking, alcohol and illicit drug use, prescription drug use, inhalants, frequency, consequences
<<Clinical Details:Alcohol>>
<<Clinical Details:Smoking>>

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

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

Comments: <<Measurements - any 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 examination - 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? <<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, 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	
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>>