Comprehensive Health and Developmental Assessment >12 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 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 young person e.g. to healthcare providers, Child Safety? Choose an item. Gillick competent? Choose an item. 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 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 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? No further action required Further information / 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 No further action required Further information / action required EATING / EXERCISE Nutrition, vegan/vegetarian, weight gain/loss, physical activity, fitness, preoccupation with weight/body image, any restricting/purging/supplements No further action required Further information / 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 No further action required Further information / action required DRUG & ALCOHOL USE Smoking, alcohol and illicit drug use, prescription drug use, inhalants, frequency, consequences No further action required Further information / action required SEXUALITY & GENDER Contraception, consent, level of knowledge, sexually activity, age of onset, safe sex practices, same sex attraction, sexual identity, STI screening, unwanted sex/sexual abuse No further action required Further information / action required SUICIDE & MENTAL HEALTH Depressed mood, anxiety Sx, sleep disturbances, self-harm, suicidal ideation/intention/method/past attempts, MSE No further action required Further information / action required SAFETY / SPIRITUALITY Bullying, abuse, traumatic experiences, risky behaviour, belief, religion, what gives them a sense of meaning 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: Normal Abnormal – further action required Comment: BRIEF SYSTEMS REVIEW GENERAL APPEARANCE, including skin Normal Abnormal / further action required Declined / not performed SPEECH & LANGUAGE Normal Abnormal / further action required Declined / not performed ORAL & DENTAL HEALTH e.g. last dental check Normal Abnormal / further action required Declined / not performed EAR, NOSE & THROAT e.g. otoscopy, tonsils, nasal polyps Normal Abnormal / further action required Declined / not performed VISION Normal Abnormal / further action required Declined / not performed CARDIAC Heart rate and rhythm, BP and cardiac auscultation Normal Abnormal / further action required Declined / not performed RESPIRATION EXAMINATION Normal Abnormal / further action required Declined / not performed CHEST EXAMINATION Normal Abnormal / further action required Declined / not performed NEUROLOGICAL EXAMINATION Normal Abnormal / further action required Declined / not performed GAIT & SPINAL EXAMINATION Musculoskeletal structure, balance, coordination Normal Abnormal / further action required Declined / not performed SIGNS OF PUBERTY Tanner stage (self reported) Normal Abnormal / further action required Declined / not performed GYNAECOLOGICAL EXAM if required Early CST Normal Abnormal / further action required Declined / not performed ANY OTHER OBSERVED CONCERNS 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 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 young person) with: Parent Child Safety My Health Record Carer Nurse Navigator Other health professionals involved in child’s care: