Preliminary Health Check	(Affix patient identification label here)
Name: Date of birth: Click or tap to enter a date. Assigned sex: Choose an item. Assessment date: Click or tap to enter a date. Age at time of assessment: Gender: Choose an item. Are you of Aboriginal or Torres Strait Islander origin? Choose an item. Other cultural and linguistic diversity: Child’s Legal Guardian Name Contact details Other key stakeholders Service (NDIS/ECEI/Child Safety) Contact person name Contact details Does this child have a My Health Record? Choose an item. Confidentiality Statement provided? Choose an item. Consent given for sharing of information in the best interests of the child/young person e.g. to healthcare providers, Child Safety? Choose an item. Refer to Supporting Health History e.g. Red Book, information from Child Safety PRESENTING CONCERNS e.g. carer concerns and child’s main worry MEDICATIONS e.g. over the counter, alternative medications IMMUNISATION HISTORY e.g. AIR records, check for multiple Medicare numbers No further action required Further information / action required EXAMINATION Height (cm): Normal Abnormal – further action required Comment: Weight (kg): Normal Abnormal – further action required Comment: BMI: (plot on Growth Chart) Normal Abnormal – further action required Comment: Temperature: Normal Abnormal – further action required Comment: Head circumference: cm Normal Abnormal – further action required Comment: Examination findings: LEARNING AND DEVELOPMENT (speech/language incl. hearing, gross motor, fine motor, social, cognitive) e.g. early childhood education/school attendence, developmental milestones, known neurodevelopmental diagnosis or learning issue, intellectual impairment Normal Abnormal / further action required Declined / not performed ANY OTHER OBSERVED CONCERNS e.g. developmental, social, practitioner concerns Normal Abnormal / further action required Declined / not performed Date for Comprehensive Health and Developmental Assessment: Click or tap to enter a date. Book long appointment and review the local HealthPathway prior e.g. children and young people in care, child development PERSON COMPLETING ASSESSMENT Clinician name: Date: Click or tap to enter a date. Designation / practice: Signature: Provider number: Time taken to complete health check (minutes): Date for review: Click or tap to enter a date. 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: Parent Child Safety My Health Record Carer Nurse Navigator Other health professionals involved in child’s care: