D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
Child HistoryMidwife, Child Health Nurse, RAN, AHW to complete
First Name
Surname
Known asOther name
Address
Other communities visited often
Ethnicity (circle) 1. AB 2. TSI 3. TSI/AB 4 not AB/TSI 5. Unknown
DOB / /
HRN
Medicare Number
Mother’s name Father’s name
Main carer: Mother Grandmother Aunty Other(Circle) (Specifiy) Carer’s name
Who supports carer at home? Language used at home
Key family members Brothers’/sisters’ names Important family history
Mother’sHRN
Place of birth - RDH DPH ASH KH TCH GDH Date discharged / /Other (name)
Mode of birth NVB Breech Caesarian Vacuum Forceps GestationAPGAR 1min 5min
Birthweight
Discharge weight
Birth length
Head Circ
Birth vaccines given Yes No
Newborn exam completed? Yes No List any birth/neonatal problems/abnormalities (add to recall as needed) N/A
Neonatal Screening? Yes NoNeonatal Hearing Screen? Yes NoFollow up Hearing screen needed? Yes NoBreast Feeding at hospital discharge? Yes No
Breast Feeding Exclusively? Yes No
Problems with Breast Feeding
Syphilis serology needed? Yes NoAdded to recall? Yes No
List any maternal complications
Hep B serology needed? Yes No Added to recall? Yes No
FOLLOW UP APPOINTMENTS POST DISCHARGEProblem Appointment with Place follow up Date follow up
General comments
Name of personcompleting history
Signature AHW RN Date / /
O
bste
tric
and
birt
h hi
stor
y
Fam
ily d
etai
ls
Chi
ld d
etai
ls
Child History 1
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
Risk AssessmentMidwife, Child Health Nurse, RAN, AHW to complete
For all children tick boxes that match identified risk factorsTo be completed by the 8 week check or for any new child to communityThe purpose of completing the Risk Assessment is to identify children and families who may require additional supportIf any of these risk factors are present:1. Discuss with the primary carer and develop a care plan if needed2. Domestic or family violence contact other services for support3. Mental health/substance misuse contact other services for support4. Provide brief intervention for any identified problems
Children and families who need close support and follow up by the Primary Health Care Team at the health centreAND review by the visiting paediatrician (add to recall)
Low birth weight (<2,500 gms) Known disability or illness
Premature birth (<37 weeks) Siblings with malnutrition or FTT
Difficult birth or neonatal problems/illness Siblings notified to NT Families and Children (FACS)
Twins or triplets History of alcohol or drug use in pregnancy
General comments
Children and families who need close support and follow up by the Primary Health Care Team at the health centre
First time or young mother Lack of social support/isolation
Single mother Domestic and/or family violence
Mother or care with disability Gambling
Other children in family with disabilities Financial stress (can’t meet basic family needs)
Mental Health issues of parents/carer including PND Recent family stress(eg. deaths or serious illness in family)
Substance use in immediate family Alcohol Marijuana Other (specify)
Action Required Yes No Details: Prompt for “Added to recall” Yes No
General comments
Name of personcompleting history Signature AHW RN Date / /
2 Risk Assessment
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009
Discussion points are in a black box. Tick as completed
First Name Surname
DOB / / Age (Weeks)
Carer attending
HRN
Child history completed? Yes No
Date Review / /
Any current concerns? (ask about general health, crying, sleeping)
Significant illnesses at time of review
Postnatal issues for mother?(Refer to Women’s Business Manual)
Weight Plotted on growth chart? Yes No
Weight gain since discharge from hospital? Yes NoIs the weight gain sufficient? Yes NoSigns of bonding/attachment present? Yes No(close contact, eye contact, concern, care, pride) If no consider referral for support
Umbilicus healing? Yes NoAny concerns about feeding? Since this time yesterday has the baby had
Breast milk Formula Other milkOther (specify)
BREAST FEEDING is best for baby - encourage exclusive breast feedingORAL HEALTH Healthy mouth for baby starts with mothers good oral health. Bad germs can go from your mouth to baby’s mouth in your spit. Remember to brush your teeth twice a day with fluoride toothpaste and visit the dentist for a checkHYGIENE Bath the baby regularly - at least every second day and wash your hands after changing nappiesSIDS PREVENTION To help keep baby safe when sleeping, lie baby on back in clean flat place. Keep baby cool. Don’t wrap too tightly - make sure baby’s head and arms are free to move. Don’t share the bed with baby if you or your husband or boyfriend have been drinking grog, smoking gunja or using other drugs. Keep the baby away from cigarette and campfire smoke. INJURY PREVENTION Car seats and seat belts protect kids AND adults in the car
Number of people living in the house: Adults Children Does anyone smoke in the house or car Yes NoIf yes consider brief intervention (SNAPE)
Are there any urgent housing repairs? Yes No Action taken:
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Action and follow upIssue or problem Referral or action made Referral to
MO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
General comments
□ Prompt for 8 week check□ 2nd Weekly recall for GAA□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check Signature AHW RN Date / /
H
ome
N
utrit
ion
Gen
eral
che
ck
C
hild
det
ails
Under 5s ProgramFirst AssessmentMidwife, Child Health Nurse, RAN, AHW to complete
First Assessment 3
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
8 Week AssessmentMidwife, Child Health Nurse, RAN, AHW and MO to complete
Discussion points are in a black box. Tick as completedFirst Name Surname
DOB / / Age (Weeks)
Carer attending
HRN
Child history completed? Yes No
Date Review / /
Problems Identified at previous check:
Any current concerns (ask about general health, crying, sleeping)
Significant illnesses at time of review
Any concerns about hearing? Yes No
Any concerns about vision? Yes No
Any concerns about general development? Yes NoSigns of bonding/attachment present? Yes No(close contact, eye contact, concern, care, pride) If no consider referral for support
Has the mother had her Post Natal Check (PNC)? Yes No(If no refer to midwife or DMO and consult WBM)
DEVELOPMENTAL POINTERSAt eight weeks babies should be smiling at carer and responsive to loud sounds. They should be able to fix on and follow a face. They should be developing some head control when pulled to sit.If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Complete head lag Not following with eyes Not smiling
Baby very floppy or stiff Does not startle at loud noises
Family concerns
Comments about development
COMMUNICATE Look into your baby’s eyes and smile at him/her. Breast feeding is a good time to do thisBREAST FEEDING Is best for baby - encourage exclusive breast feeding. Babies do not need anything but breastmilkORAL HEALTH Healthy mouth - starts with mother’s good oral health. Bad germs can go from your mouth to baby’s mouth in your spit. Remember to brush your teeth twice a day with fluoride toothpaste and visit the dentist for a check
Since this time yesterday has the baby had
Breast milk Formula Other milk Tea Water Soft drink/cordial/fruit juice (these can damage teeth)Other (specify)
Any concerns about feeding?
HYGIENE Bath baby regularly - at least every second day. Wash your hands after changing nappies. Keep baby’s and other children’s face and hands clean to stop germs from pus affected ears and noses spreadingSIDS PREVENTION To help keep baby safe when sleeping, lie baby on back in clean flat place. Keep baby cool. Don’t wrap too tightly - arms are free to move. Don’t share the bed with baby if you or your husband or boyfriend have been drinking grog, smoking marijuana or using other drugs. Keep the baby away from cigarette and campfire smoke
INJURY PREVENTION Car seats and seat belts protect kids AND adults in the car
Number of people living in the house: Adults Children Does anyone smoke in the house/car? Yes NoIf yes consider brief intervention (SNAPE)
Are there any urgent housing repairs? Yes No Housing referral made? Yes NoDomestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Hom
e
Nut
ritio
n
Dev
elop
men
t
G
ener
al c
heck
Child
det
ails
8 Week Assessment 4
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
8 Week Examination
WeightWeight gain satisfactory? Yes No Plot on growth chart
Action Plan needed? Yes No
2 month immunisation given? □ Yes □ Already □ This visit (Record on immunisation sheet)
□ Unable to give - place on recallLength Head Circ.
Fontanelles AF Open Closed PF Open Closed
Skin Clear Scabies Sores Ringworm Other (specify)
Treatment
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
Treatment
CVS Heart sounds Normal AbnormalFemoral pulses present? Yes No
R hip Normal AbnormalL hip Normal Abnormal
R testis descended Yes NoL testis descended Yes No
General appearance and comments
Action and follow upMake a note on the 4 month form of any problems that need follow up
Issue or problem Referral or action made Referred to
MO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
General comments
□ Prompt for 4 month check □ Medicare claim 708 completed□ Monthly recall for GAA□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check
Signature AHW RN DR Date / /
Med
ical
Offi
cer E
xam
inat
ion
Exam
inat
ion
5 8 Week Examination
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
4 Month AssessmentChild Health Nurse, RAN or AHW to complete
Discussion points are in a black box. Tick as completedFirst Name
Surname
DOB / / Age (Weeks)
HRN
Date Review / /
Carer attending
4 month immunisation given? □ Yes □ Already □ This visit (Record on immunisationsheet)
□ Unable to give - place on recall
Problems identified at previous check:
Any current concerns? (general health, crying, sleeping)
Significant illnesses at time of review: Signs of bonding/attachment present? Yes No(close contact, eye contact, concern, care, pride) If no consider referral for support
WeightIs growth following curve? Yes No
Action required? Yes No
Details:Skin Clear Scabies Sores Ringworm Other (specify)
Treatment
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
Treatment
Since this time yesterday has the baby hadBreast milk Formula Other milk Tea Water Soft drink/Cordial/Fruit juice Other (specify) (these can damage teeth)
BREAST FEEDING Is best for baby - encourage exclusive breast feeding. Wait until 6 months before starting solid food
HYGIENE Keep baby’s face and hands clean to stop germs spreading from pus affected ears and runny noses. Bath baby regularly- at least every second day. Wash hands after changing nappies. Use tissue spears to clean ears. Keep baby away from smoke to reduce the risk of ear diseaseSIDS PREVENTION To help keep baby safe when sleeping, lie baby on back in clean flat place. Keep baby cool. Don’t wrap too tightly so arms are free to move. Don’t share the bed with baby if you or your husband or boyfriend have been drinking grog, smoking marijuana or using other drugs. Keep the baby away from cigarette and campfire smokePLAY Let baby have play time on tummy every day
COMMUNICATE Talk to your baby and get a conversation going with sounds or gesturesDomestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Action and follow upMake a note on the 6 month form of any problems that need follow up
Issue or problem Referral or action made Referred toMO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
□ Prompt for 6 month check □ Monthly recall for GAA□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check Signature AHW RN DR Date / /
Hom
e
Nut
ritio
n
Exa
min
atio
n
G
ener
al c
heck
C
hild
det
ails
4 Month Assessment 6
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009
Discussion points are in a black box. Tick as completedFirst Name
Surname
DOB / / Age (Weeks)
HRN
Date Review / /
Carer attending
Problems Identified at previous check:
Any current concerns? (ask about general health, crying, sleeping) Any concerns about hearing? Yes No
Any concerns about vision? Yes No
Any concerns about general development? Yes No
Significant illnesses in last 6 months? Signs of bonding/attachment present? Yes No(close contact, eye contact, concern, care, pride) If no consider referral for support
DEVELOPMENTAL POINTERSAt this age babies are laughing and interacting with their families. At 6 months, babies should be able to make eye contact and follow a person with their eyes. They should be able to turn their heads to familiar voices and sounds and make baby sounds. They roll from front to back and back to front. They reach for objects using both hands and are starting to transfer objects from one hand to the otherIf any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Preference for one hand Not turning head to soft voice Family concerns
Squint Not interested in people
Comments about development
Is the child attending playgroup/early childhood development activities on a regular basis? Yes No NA
PLAY Give your child safe household things to handle, bang and drop
COMMUNICATE Respond to your baby’s sounds and interests. Tell your baby the names of things and people
HYGIENE Keep baby’s face and hands clean to stop germs spreading from pus affected ears and runny noses. Bath baby regularly-at least every second day. Wash hands after changing nappies. Use tissue spears to clean ears. Make sure area is clean and safe for babyINJURY PREVENTION Because baby is rolling now, be careful putting them up high or leaving them near fires - baby may fall off ledges or roll into firesNUTRITION It’s time to start giving your baby solids. Keep breast feeding. (Use NT infant feeding guidelines to show recommended foods and fluids as shown in ‘A story about feeding babies’ Include quantity, times per day and food safety issues.)
Since this time yesterday has the baby had
Breast milk Formula Other milk Tea Water Soft drink/Cordial/Fruit juice Other (specify) (these can damage teeth)Has the baby started on solids? Yes No List (if yes)
Number of people living in the house: Adults Children Does anyone smoke in the house/car? Yes NoIf yes consider brief intervention (SNAPE)
Are there any urgent housing repairs? Yes No Housing referral made? Yes No
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.
Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Hom
e
Nut
ritio
n
Dev
elop
men
t
G
ener
al c
heck
C
hild
det
ails
Under 5s Program6 Month AssessmentChild Health Nurse, RAN or AHW to complete
6 Month Assessment 7
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009
Weight Weight gain satisfactory?
Yes No Plot on growth chart
Action Plan needed?
Yes No6 month immunisation given? □ Yes □ Already □ This visit (Record on immunisation sheet)
□ Unable to give - place on recall
Length Hb Rx (low Hb) Routine de-worm? Yes No(Refer to CARPA STM)
Skin Clear Scabies Sores Ringworm Other (specify)
Treatment
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
Recurrent episodes (3 or more) of otitis media? Yes No
Treatment
Oral health “lift the lip” and check for colour changes in baby’s teeth - white, brown or black spotsSpots seen? Yes No Referred to dental therapist? Yes No Referred to dentist? Yes NoGeneral appearance and comments Chest
□ Persistent cough > 4 weeks□ Recurrent prolonged wet cough□ 2 episodes hospitalisation - resp. illness in last 12 months□ 3 episodes hospitalisation - resp. illness since birthIf yes to any, refer for medical review and record below
ORAL HEALTH Start caring for baby’s new teeth when they first come through. Clean with a damp clean cloth (don’t use toothpaste until 18 months). Check teeth and gums regularly for any colour changes. It is important for mum, dad and baby to clean teeth twice a day
Action and follow upMake a note on the 9 month form of any problems that need follow up
Issue or problem Referral or action made Referred to
MO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
General comments
□ Prompt for 9 month check □ Monthly recall for GAA□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check Signature AHW RN Date / /
Exam
inat
ion
Under 5s program6 Month ExaminationChild Health Nurse, RAN or AHW to complete
8 6 Month Examination
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009
Discussion points are in a black box. Tick as completedFirst Name Surname
DOB / / Age (Weeks)
HRN
Date Review / /
Carer attending
Immunisation □ Given (record on immunisation sheet)
□ Up to date □ Unable to give - placed on recall
Problems identified at previous check
Weight Growth satisfactory? Yes NoPlot on growth chart Action plan needed? Yes No
Since this time yesterday has the baby hadBreast milk Formula Other milk Tea Water Soft drink/cordial/fruit juice Other (these can damage teeth)Is the child eating solids regularly? Yes NoWhat foods Nutritional information and advice given? Yes No Use NT Infant feeding guidelines
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
TreatmentRecurrent otitis media? (3 or more episodes in 6 months) Yes NoPersistent otitis media? (more than 3 months with perforation) Yes NoHearing referral required? Yes No (if yes record below)
Skin Clear Scabies Sores Ringworm Other (specify)
Treatment
Oral health “lift the lip” and check for colour changes in baby’s teeth white, brown or black spotsSpots seen? Yes No Referred to dental therapist? Yes No Referred to dentist? Yes No
General appearance and comments
PLAY GIve your child clean safe household things to handle, bang and drop
COMMUNICATE Respond to your child’s sounds and interests. Tell your child the names of things and people. Read books to your child and talk about the picturesNUTRITION Introduce lumpier food (Use the flipchart ‘A story about feeding babies’ nutrition advice from NT Infant Feeding Guidelines)
HYGIENE Keep face/hands clean to stop germs spreading from pus affected ears and runny noses. Use tissue spears to clean ears. Bath baby regularly - at least every second day
ORAL HEALTH Start caring for baby’s new teeth when they first come through. Clean with a damp clean cloth (don’t use toothpaste until 18 months). Check teeth and gums regularly for any colour changes. It is important for mum and dad and baby to clean teeth twice a day
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Action and follow upMake a note on the 12 month form of any problems that need follow up
Issue or problem Referral or action made Referred toMO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
□ Prompt for 12 month check □ Monthly recall for GAA□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check
Signature AHW RN Date / /
Under 5s Program9 Month AssessmentChild Health Nurse, RAN or AHW to complete
H
ome
Exa
min
atio
n
N
utrit
ion
C
hild
det
ails
9 Month Assessment 9
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009
Discussion points are in a black box. Tick as completedFirst Name
Surname
DOB / / Age
HRN
Date Review / /
Carer attending Problems Identified at previous check
Any current concerns (ask about general health, crying, sleeping) Significant illnesses in last 6 months?
Any concerns about hearing? Yes NoAny concerns about vision? Yes NoAny concerns about general development? Yes No
DEVELOPMENTAL POINTERSOne year olds should be mobile - crawling, bottom shuffling, starting to walk with support. They should be able to pick up small objects (eg. eat solid food with fingers) and manipulate objects well. They should be starting to talk, saying single words with meaning and understanding simple instructional words (eg food, drink, car)If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Not sitting without support No interest in people Not understanding simple spoken words
Not pulling to stand Not developed pincer grasp Family concerns
Comments about development
Is the child attending playgroup/early childhood development activities on a regular basis? Yes No
COMMUNICATE Ask your child simple questions. Respond to your child’s attempts to talk. Play games: Ask child to wave bye-bye.Read books with your child and talk about the picturesINJURY PREVENTION Now your child is becoming more mobile, watch closely around the campfire - keep safe from injuries and burns. Watch closely around water - keep safe from drowningHYGIENE Keep child’s face and hands clean to stop germs spreading from pus affected ears and runny noses. Use tissue spears to clean ears and bath or shower at least every second dayPLAY Allow child to explore safely - always supervise
NUTRITION Start family foods - 3 meals and 2 snacks. Refer to NT infant feeding guidelines as shown in ‘A story about feeding babies’Is the child eating solids regularly? Yes No
Since this time yesterday has the baby had
Breast milk Formula Other milk Tea Water Soft drink/Cordial/Fruit juice (these can damage teeth)Other (specify)
Other foods
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Hom
e
Nut
ritio
n
D
evel
opm
ent
G
ener
al c
heck
C
hild
det
ails
Under 5s Program12 Month AssessmentChild Health Nurse, RAN, AHW and MO to complete
12 Month Assessment 10
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
12 Month ExaminationWeight Weight gain satisfactory?
Yes No
Plot on growth chart
Action Plan needed?
Yes No
12 month immunisation given? □ Yes □ Already □ This visit (Record on immunisation sheet) □ Unable to give - place on recallLength
Hb Rx (low Hb) Routine de-worm? Yes No
Oral health “lift the lip” note colour and checkGums Healthy Bleeding Abscess Not sureTeeth Healthy White spots Caries Not sure If caries present 1-3 teeth 4 or more teethDental referral required? Yes No Dental referral urgent? Yes No
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
Treatment
Tympanometry Normal Not normal Not doneRecurrent otitis media? (3 episodes in 6 months) Yes NoPersistent otitis media? (more than 3 months with perforation) Yes NoHearing referral required: Yes No (If yes record below)
Skin Clear Scabies Sores Ringworm Other (specify) Treatment
CVS Heart Sounds Normal Abnormal
General appearance and comments Chest
□ Persistent cough > 4 weeks□ Recurrent prolonged wet cough□ 2 episodes hospitalisation - resp. illness in last 12 months□ 3 episodes hospitalisation - resp. illness since birthIf yes to any, refer for medical review and record
ORAL HEALTH Remember to clean teeth twice a day - Consider low fluoride toothpaste if water is not fluoridatedEAR HEALTH It’s good to start to teach the child how to blow their nose. Nose blowing helps to keep ears clear and helps stop germs spreading to other babies in the family. Encourage carers to use tissue spears for pus affected ears. Throw tissues into a bin and wash your hands after cleaning ears.
Action and follow upMake a note on the 18 month form of any problems that need follow up
Issue or problem Referral or action made Referred to
MO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
General appearance and comments
□ Prompt for 18 month check □ Medicare claim 708 completed□ Monthly recall for GAA□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check
SignatureAHW RN DR Date / /
Med
ical
Offi
cer E
xam
inat
ion
Ex
amin
atio
n
11 12 Month Examination
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
18 Month AssessmentChild Health Nurse, RAN, AHW to complete
Discussion points are in a black box. Tick as completed
First Name
Surname
DOB / / Age
HRN
Date Review / /
Carer attending
Problems Identified at previous check
Any current concerns (ask about general health, crying, sleeping) Significant illnesses in last 6 months?
Any concerns about hearing? Yes NoAny concerns about language? Yes NoAny concerns about development? Yes No
DEVELOPMENTAL POINTERSAt 18 months children should be able to say at least six words in English or community language (eg. mum, dad, ball, milk, all gone). They can point to familiar items on request (eg. body parts). They should be holding a cup and drinking from it and starting to feed themselves with a spoon. They should be able to stop and pick up objects they have dropped. They should be walking (backwards and forwards) and climbing. They tend to play for a couple of minutes and be curious about what is going on around them.If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
No constructive play Not pointing at items Poor eye contact
Not saying 6 words Not walking alone Not engaging in group activities
Comments about development Family concerns
Is the child attending playgroup/early childhood development activities on a regular basis? Yes No NA(Encourage attendance if available in community)
COMMUNICATE To help your child learn to talk, it’s good to tell stories and sing. It’s good to use and encourage English as well as community language. It’s good to talk to your child during daily tasks like cooking and sweeping
NUTRITION 3 meals per day plus 2 snacks. Refer to NT infant feeding guidelines as shown in ‘A story about feeding babies’Is the child eating solids regularly? Yes No
Since this time yesterday has the baby had
Breast milk Formula Other milk Tea Water Soft drink/Cordial/Fruit juice Other (specify) (these can damage teeth)Other foods
HYGIENE The child is now old enough to start learning how to use the toilet and how to wash hands and face with soap and water
Number of people living in the house: Adults Children Does anyone smoke in the house/car? Yes NoIf yes consider brief intervention (SNAPE)
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Hom
e
N
utrit
ion
Dev
elop
men
t
Gen
eral
che
ck
C
hild
det
ails
18 Month Assessment 12
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
18 Month ExaminationWeight Weight gain satisfactory?
Yes No
Plot on growth chart
Action Plan needed?
Yes No
18 month immunisation given? □ Yes □ Already □ This visit (Record on immunisation sheet)
□ Unable to give - place on recallLength
Hb Rx (low Hb) Routine de-worm? Yes No NA
Oral health “lift the lip” note colour and checkGums Healthy Bleeding Abscess Not sureTeeth Healthy White spots Caries Not sure If caries present 1-3 teeth 4 or more teethDental referral required? Yes No Dental referral urgent? Yes No
Fluoride varnish applied?
□ Yes Next due / / (Every 6 months)
□ No □ Not able □Already done
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
Treatment
Tympanometry Normal Not normal Not doneRecurrent otitis media? (3 or more episodes in 6 months) Yes NoPersistent otitis media? (more than 3 months with perforation) Yes NoHearing referral required Yes No (If yes record below)
Skin Clear Scabies Sores Ringworm Other (specify)
Treatment
General appearance and comments Chest
□ Persistent cough > 4 weeks□ Recurrent prolonged wet cough□ 2 episodes hospitalisation - resp. illness in last 12 months□ 3 episodes hospitalisation - resp. illness since birthIf yes to any, refer for medical review and record
ORAL HEALTH Child is now old enough for teeth to be cleaned with a small soft toothbrush and a pea size amount of child’s low fluoride toothpaste. Lift the lip to check the teeth and gums for colour changesEAR HEALTH It’s good to start to teach the child how to blow their nose. Nose blowing helps to keep ears clear and helps stop germs spreading to other babies in the family
Action and follow upMake a note on the 2 year form of any problems that need follow up
Issue or problem Referral or action made Referred to
MO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
General comments
□ Prompt for 2 year check □ Monthly recall for GAA□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check Signature AHW RN Date / /
Exam
inat
ion
13 18 Month Examination
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009
Discussion points are in a black box. Tick as completedFirst Name
Surname
DOB / / Age
HRN
Date Review / /
Carer attending Problems Identified at previous check
Any current concerns (ask about general health) Significant illnesses in last 6 months?
Any concerns about hearing? Yes NoAny concerns about vision? Yes NoAny concerns about general development? Yes No
DEVELOPMENTAL POINTERSTwo year olds should be able to say 50 to 100 words and use two words together (eg go car, mum drink). They should be able to answer simple questions (say name when asked, “get your shoes”. They should be developing some fine motor skills (eg undressing themselves with some help with buttons). They should be very mobile - walking, running, jumping, climbing. They should be able to kick and throw a large ball. They should enjoy interactive games and playing with other children.If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Not running Not answering simple questions
Not interested in other children Not talking well in language
Comments about development Family concerns
Is the child attending playgroup/early childhood development activities on a regular basis? Yes No NA(Strongly encourage attendance if available in community)
INJURY PREVENTION Need to watch children near roads and creeks, keep off the road and other dangers. Make sure children don’t climb too high - falls from high places can cause injuryPLAY Vigorous outside play for as long as practicable, teaching to climb safely, run, hop, jump, kick, throw and catch balls
COMMUNICATE Encourage your child to talk and answer their questions. Teach your child stories, songs and games in English as well as community language
Since this time yesterday has the baby had
Breast milk Formula Other milk Tea Water Soft drink/Cordial/Fruit juice Other (specify) (these can damage teeth)Other foods
ORAL HEALTH It’s good to drink water and limit sugary food and drinks to help keep teeth healthy. Brush your child’s teeth twice a day using a small soft toothbrush and a pea size amount of child’s low fluoride toothpasteHYGIENE Encourage your child to use the toilet. It’s good to encourage your child to wash their hands and face with soap. Encourage your child to blow their nose. Nose blowing helps to keep ears clear and helps stop germs spreading to other babies and children in the family
NUTRITION 3 meals per day plus 2 snacks. Refer to NT infant feeding guidelines as shown in ‘A story about feeding babies’
Number of people living in the house: Adults Children Does anyone smoke in the house/car? Yes NoIf yes consider brief intervention (SNAPE)
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Hom
e
N
utrit
ion
Dev
elop
men
t
Gen
eral
che
ck
Chi
ld d
etai
ls
Under 5s Program2 Year AssessmentChild Health Nurse, RAN, AHW and MO to complete
2 Year Assessment 14
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
2 Year Examination
Weight Height (standing) Growth satisfactory? Yes NoPlot on growth chart
Action plan? Yes No
Hb Rx (low Hb) Routine de-worm?
Yes No NA
Immunisation □ Given (record on immunisation sheet)
□ Up to date□ Unable to give - placed on recall
Oral health “lift the lip” note colour and checkGums Healthy Bleeding Abscess Not sureTeeth Healthy White spots Caries Not sure If caries present 1-3 teeth 4 or more teethDental referral required? Yes No Dental referral urgent? Yes No
Fluoride varnish applied?
□ Yes Next due / / (Every 6 months)
□ No □ Not able □Already done
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
Treatment
Tympanometry Normal Not normal Not doneRecurrent otitis media? (3 or more episodes in 6 months) Yes NoPersistent otitis media? (more than 3 months with perforation) Yes NoHearing referral required Yes No (If yes record below)
Skin Clear Scabies Sores Ringworm Other (specify)
Treatment
General comments Chest
□ Persistent cough > 4 weeks□ Recurrent prolonged wet cough□ 2 episodes hospitalisation - resp. illness in last 12 months□ 3 episodes hospitalisation - resp. illness since birthIf yes to any, refer for medical review and record
CVS Heart Sounds Normal Abnormal
Action and follow upMake a note on the 3 year old form of any problems that need follow up
Issue or problem Referral or action made Referred to
MO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
General appearance and comments
□ Prompt for 3 year check □ Medicare claim 708 completed□ 6 Monthly GAA check due at 2½ years□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check Signature AHW RN DR Date / /
Med
ical
Offi
cer
Exam
inat
ion
Exam
inat
ion
15 2 Year Examination
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009
Discussion points are in a black box. Tick as completedFirst Name Surname
DOB / / Age
HRN
Date Review / /
Carer attendingProblems Identified at previous check
Any current concerns (ask about general health) Significant illnesses in last 6 months?
Any concerns about hearing? Yes NoAny concerns about vision? Yes NoAny concerns about general development? Yes NoDEVELOPMENTAL POINTERSA three year old child should be starting to use 3-word sentences and following simple 2-step instructions (eg “get shirt from room”) and should be starting to ask a lot of questions. They should be able to put on a T-shirt/shorts. A 3 year old should be able to throw and kick a ball and should be starting to learn to walk up/down stairs without holding on. They should be able to copy a line and a circle and imitate simple tasks such as cleaning if they have been exposed to these skills.If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Not putting words together in phrases Not engaging in active play with peers
Not understanding simple instructions Unable to kick a ball
Comments about development Family Concerns
Is the child attending playgroup/early childhood development activities on a regular basis? Yes No NA(Strongly encourage attendance if available in community)
INJURY PREVENTION Car seats and seat belts protect kids in the car. Need to watch kids don’t climb too high - falls from high places can cause injuries. Keep poisons and medicines up high and in their packets helps keep kids safePLAY Vigorous outside play for as long as practicable teaching to climb safely, run, hop, jump, kick, throw and catch balls
COMMUNICATE Encourage your child to talk and answer their questions. Teach your child stories, songs and games in English as well as community language
Since this time yesterday has the baby had
Milk Water Tea Soft drink/Cordial/Fruit juice Other (these can damage teeth)Other foods (list)
NUTRITION 3 meals per day plus 2 snacks.
ORAL HEALTH Help your child to brush their teeth twice a day using a small soft toothbrush and a pea size amount of child’s fluoride toothpaste. Decayed teeth are painful and need immediate treatment from a dentist or dental therapistHYGIENE Encourage your child to use the toilet. It’s good to encourage your child to wash their hands and face with soap after using the toilet and before meals. Encourage your child to blow their nose. Nose blowing helps to keep ears clear and helps stop germs spreading to other babies and children in the family
Number of people living in the house: Adults Children Does anyone smoke in the house/car? Yes NoIf yes consider brief intervention (SNAPE)
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form
Hom
e
Nut
ritio
n
D
evel
opm
ent
Gen
eral
che
ck
Chi
ld d
etai
ls
Under 5s Program3 Year AssessmentChild Health Nurse, RAN, AHW and MO to complete
3 Year Assessment 16
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
3 Year ExaminationWeight Height (standing) Growth satisfactory? Yes No
Plot on growth chartImmunisation □ Given (record on immunisation sheet)
□ Up to date□ Unable to give - placed on recall
Hb Rx (low Hb) Routine de-worm? Yes No NA
Oral health “lift the lip” note colour and checkGums Healthy Bleeding Abscess Not sureTeeth Healthy White spots Caries Not sure If caries present 1-3 teeth 4 or more teethDental referral required? Yes No Dental referral urgent? Yes No
Fluoride varnish applied?
□ Yes Next due / / (Every 6 months)
□ No □ Not able □Already done
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
Treatment
Tympanometry Normal Not normal Not doneRecurrent otitis media? (3 or more episodes in 6 months) Yes NoPersistent otitis media? (more than 3 months with perforation) Yes NoHearing referral required Yes No (If yes record below)
Skin Clear Scabies Sores Ringworm Other (specify)
Treatment
General appearance and comments Chest
□ Persistent cough > 4 weeks□ Recurrent prolonged wet cough□ 2 episodes hospitalisation - resp. illness in last 12 months□ 3 episodes hospitalisation - resp. illness since birthIf yes to any, refer for medical review and record
CVS Heart Sounds Normal Abnormal
Action and follow upMake a note on the 4 year old form of any problems that need follow up
Issue or problem Referral or action made Referred to
MO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
General comments
□ Prompt for 4 year check □ Medicare claim 708 completed□ 6 Monthly GAA check due at 3½ years□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)Name of personcompleting check Signature AHW RN DR Date / /
Med
ical
Offi
cer
Exam
inat
ion
Exam
inat
ion
17 3 Year Examination
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009
Discussion points are in a black box. Tick as completedFirst Name
Surname
DOB / / Age
HRN
Date Review / /
Carer attending
Problems Identified in medical history
Any current concerns (ask about general health) Significant illnesses in last 6 months?
Any concerns about hearing? Yes NoAny concerns about language? Yes NoAny concerns about general development? Yes No
Since this time yesterday has your child had
Milk Tea Water Soft drink/Cordial/Fruit juice Other (specify) (these can damage teeth)Other foods (list)
DEVELOPMENTAL POINTERSA 4 year old child should be able to listen to and understand simple stories. They should be able to tell stories and ask questions speaking clearly (in language) and be able to be understood. They should be able to dress themselves, walk along a log, play ball games, enjoy playing with other children and understand taking turns games.If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Not using the toilet Unable to convey messages
Unable to dress self Family concerns
Comments about development
Has the child started pre-school? Yes No NA(Strongly encourage attendance if available in community)
SOCIAL Help prepare children for school by being involved with the school and letting children know that parents/carers think school is important. Parents reading to children regularly helps children to learn to readPLAY Vigorous outside play - restrict TV/electronic games to less than 2 hours per day
BOOKLET Hand out and discuss the booklet: “Get Set 4 Life- Habits for Healthy Kids”
NUTRITION 3 meals per day plus 2 snacks. See the booklet: “Get Set 4 Life- Habits for Healthy Kids” (pages 12-15)
General comments
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with any problems identified.Was DFV screen done at this visit? Yes No Referral made Yes No Use S&E Assessment form H
ome
D
evel
opm
ent
Nut
ritio
n
G
ener
al c
heck
Child
det
ails
Under 5s Program4 Year AssessmentChild Health Nurse, RAN, AHW and MO to complete
4 Year Assessment 18
D E PA RT M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/healthJanuary 2009Under 5s Program
4 Year ExaminationWeight Height
(standing)Growth satisfactory? Yes NoPlot on growth chart
Action plan? Yes No
BMI Is BMI in normal range? Yes No Hb Routine de-worm? Yes No NA
Oral health “lift the lip” note colour and checkGums Healthy Bleeding Abscess Not sureTeeth Healthy White spots Caries Not sure If caries present 1-3 teeth 4 or more teethDental referral required? Yes No Dental referral urgent? Yes No
Fluoride varnish applied?
□ Yes Next due / / (Every 6 months)
□ No □ Not able □Already done
4 year immunisation given? □ Yes □ Already □ This visit (Record on immunisation sheet)
□ Unable to give - place on recall□ Up to date
R ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
L ear □ NAD □ AOM □ AOM w Perf. □ CSOM □ OME □ Dry Perf. □ Otitis Ext. □ Other (specify)
Treatment
Tympanometry Normal Not normal Not doneRecurrent otitis media? (3 or more episodes in 6 months) Yes NoPersistent otitis media? (more than 3 months with perforation) Yes NoHearing referral required Yes No (If yes record below)
Hearing Screening - Only if no ear disease presentR ear 25dB 1000Hz P F 4000Hz P F
L ear 25dB 1000Hz P F 4000Hz P F
P = Pass F = Fail (please tick)
Skin Clear Scabies Sores Ringworm Other (specify)
Treatment
Visual acuity (Lea chart)
R eye
L eye
Trachoma
R eye NAD TF TI TS
L eye NAD TF TI TS
General appearance and comments Chest
□ Persistent cough > 4 weeks□ Recurrent prolonged wet cough□ 2 episodes hospitalisation - resp. illness in last 12 months□ 3 episodes hospitalisation - resp. illness since birthIf yes to any, refer for medical review and record
CVS Heart Sounds Normal Abnormal
Action and follow upIssue or problem Referral or action made Referred to
MO Paed Other (specify)
MO Paed Other (specify)
MO Paed Other (specify)
□ Medicare claim 708 completed □ Medicare claim 709 completed □ Medicare claim 711 (RAN/AHW) completed
Name of personcompleting check Signature AHW RN DR Date / /
Med
ical
Offi
cer
Exam
inat
ion
Exam
inat
ion
19 4 Year Examination