Comprehensive Health and Developmental Assessment 0 - 11 Years	(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 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 e.g. to healthcare providers, Child Safety? Choose an item. 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 MEDICAL HISTORY e.g. allergies, hospital admissions, diagnoses, NDIS, known mental health diagnosis MEDICATIONS e.g. over the counter, alternative medications IMMUNISATION HISTORY e.g. AIR records, check for multiple Medicare numbers Normal Abnormal / further action required Declined / not performed PRESENTING CONCERNS e.g. carer concerns and young person’s main worry e.g. behaviour, sleep, school attendance EMOTIONAL WELLBEING e.g. mental health, trauma, use Strengths & Difficulties Questionnaire No further action required Further information / action required Declined / not performed 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 No further action required Further information / action required Declined / not performed SEXUAL HEALTH & BEHAVIOURS e.g. sexualised behaviour, menarche and details of cycle, sexual activity, contraception No further action required Further information / action required Declined / not performed HEALTHY EATING e.g. nutrition milk, transition to solids, appetite, range of foods eaten No further action required Further information / action required Declined / not performed PHYSICAL ACTIVITY No further action required Further information / action required Declined / not performed BLADDER & BOWEL e.g. toilet training, enuresis/nocturnal enuresis, constipation, encoperesis No further action required Further information / action required Declined / not performed EXAMINATION Height (cm): Normal Abnormal – further action required Comment: Weight (kg): Normal Abnormal – further action required Comment: BMI: Normal Abnormal – further action required Comment: Head circumference: cm Normal Abnormal – further action required Comment: GENERAL APPEARANCE e.g. dysmorphic, skin (infection, vascular malformations, neurocutaneous features), interaction with carer No further action required Further information / action required Declined / not performed HEAD e.g. fontanelles, sutures, plagiocephaly No further action required Further information / action required Declined / not performed VISION Left Eye Right Eye Appearance: Normal Abnormal/FAR Appearance: Normal Abnormal/FAR Red Reflex: Normal Abnormal/FAR Red Reflex: Normal Abnormal/FAR Fixation/cover text: Normal Abnormal/FAR Fixation/cover text: Normal Abnormal/FAR HEARING Left Ear Right Ear Appearance: Normal Abnormal/FAR Appearance: Normal Abnormal/FAR Otoscopy: Normal Abnormal/FAR Otoscopy: Normal Abnormal/FAR Audiometry: Pass Fail Audiometry: Pass Fail Tympanometry: A B C SPEECH & LANGUAGE Normal Abnormal / further action required Declined / not performed ORAL & DENTAL HEALTH e.g. last dental check, tonsils Normal Abnormal / further action required Declined / not performed CVS HR: Tachy Normal Brady Rhythm: Regular Irregular Sounds: Dual no murmurs Other Femoral pulses: Equal Unequal Brachial pulses: Equal Unequal Normal Abnormal / further action required Declined / not performed RESPIRATORY RR: Tachy Normal Sounds: Air entry equal with no added sounds Other Normal Abnormal / further action required Declined / not performed ABDOMINAL EXAMINATION Normal Abnormal / further action required Declined / not performed GENITALIA (only for baby check) Normal Abnormal / further action required Declined / not performed ANUS (only for baby check) Normal Abnormal / further action required Declined / not performed HIPS Normal Abnormal / further action required Declined / not performed UPPER LIMBS Normal Abnormal / further action required Declined / not performed LOWER LIMBS Normal Abnormal / further action required Declined / not performed NEUROLOGICAL EXAMINATION – age specific: gait, tone, power, reflexes, sensation Normal Abnormal / further action required Declined / not performed SPINE 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 INVESTIGATIONS Please consider accessing results available via The Viewer or private pathology/radiology companies & My Health Record. Normal Abnormal / further action required Declined / not performed 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 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) with: Parent Child Safety My Health Record Carer Nurse Navigator Other health professionals involved in child’s care: