UNIVERSALCHILD HEALTH RECORD
Endorsed by: 0'
American Academy of Pedlatrics,New JerseY-ChapterNew Jersey Academy 9,( F~f[llIy PhysiciansNew Jersey Department of'Health and Senior Servicas
Does Child Have Health Insurance?DYes ONo
Gendero Male 0 Female
If Yes, Name of Child's Health Insurance Carrier
Home Telephone Number Work Telephone/Cell Phone NumberParent/Guardian Name
Home Telephone NumberParent/Guardian Name Work Telephone/Cell Phone Number
I give my consent for my child's Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form.Signature/Date IThis fonm may be released to WIC.
DYes DNo
Date of Physical Examination:Abnormalities Noted:
Results of physical examination normal?
Weight(must be takenwithin 30 days for WIC)
Height (must be takenwithin 30 days for WlC)Head Circumference(if <2 Years)Blood Pressure(if ~3 Years)
IMMUNIZATIONSDlmmunization RecordAttachedDOate Next Immunization Due: __
MEDICAL CONDITIONSChronic Medical Conditions/Related Surgeries• List medical conditionslongoing surgical
concems:
DNone I CommentsDSpecial Care Plan
Attached
MedicationslTreatments• List medicationsltreatments:
DNone .OSpecial Care PlanAttached
Comments
Limitations to Physical Activity• List limitations/special considerations:
DNoneOSpecial Care Plan
Attached
Comments
·CommentsSpecial Equipment Needs• . List items necessary for daily activities
ONoneOSpecial Care Plan .
AttachedCommentsAllergies/Sensitivities
• List allergies:
DNoneOSpeclal Care Plan
Attached
Special OieWitamin & Mineral Supplements• List dietary specifications:
CommentsDNoneOSpecial Care Plan
AttachedBehavioral Issues/Mental Health Diagnosis• List behavioral/mental health
issues/concerns:
ONoneOSpecial Care PlanAttached
Comments
Emergency PlansList emergency plan that might be neededand the sion/svrnotoms to watch for:
~ I IHearingDate Performed I Record Value I Type ScreeningType Screening
ONoneOSpecial Care Plan
Attached
Comments
PREVENTIVE HEALTH SCREENINGSDate Performed Note if Abnormal
Hgb/Hct.Lead: OCapillary DVenous Vision
T8 (mm of Induration) Dental
Other:ScoliosisDevelopmental
Other:Name of Health Care Provider (Print) Heaith Care Provider Stamp:
Signature/Date