under 5s program health - remote health atlasremotehealthatlas.nt.gov.au/hu5k_forms_full_set.pdf ·...

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 / /

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Child History 1



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


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)



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 / /

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Under 5s ProgramFirst AssessmentMidwife, Child Health Nurse, RAN, AHW to complete

First Assessment 3



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

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8 Week Assessment 4



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




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 / /

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5 8 Week Examination



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



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


Issue or problem Referral or action made Referred toMO 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 / /

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4 Month Assessment 6




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


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.)


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)


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

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Under 5s Program6 Month AssessmentChild Health Nurse, RAN or AHW to complete




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)


Treatment



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






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 / /

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Under 5s program6 Month ExaminationChild Health Nurse, RAN or AHW to complete

8 6 Month Examination




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



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)


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


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



Issue or problem Referral or action made Referred toMO 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

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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


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


Breast milk Formula Other milk Tea Water Soft drink/Cordial/Fruit juice (these can damage teeth)Other (specify)

Other foods


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Under 5s Program12 Month AssessmentChild Health Nurse, RAN, AHW and MO to complete




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



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.







□ 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 / /

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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


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



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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


Fluoride varnish applied?

□ Yes Next due / / (Every 6 months)

□ No □ Not able □Already done



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)


Treatment



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





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 / /

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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


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’



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Under 5s Program2 Year AssessmentChild Health Nurse, RAN, AHW and MO to complete

2 Year Assessment 14



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







Treatment



Treatment

General comments Chest



Action and follow upMake a note on the 3 year old form of any problems that need follow up






□ 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 / /

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15 2 Year Examination




DOB / / Age

HRN

Date Review / /

Carer attendingProblems Identified at previous check


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


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



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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







Treatment



Treatment




Action and follow upMake a note on the 4 year old form of any problems that need follow up





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 / /

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Date Review / /

Carer attending

Problems Identified in medical history


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


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

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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





4 year immunisation given? □ Yes □ Already □ This visit (Record on immunisation sheet)

□ Unable to give - place on recall□ Up to date



Treatment


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)


Treatment

Visual acuity (Lea chart)

R eye

L eye

Trachoma

R eye NAD TF TI TS

L eye NAD TF TI TS




Action and follow upIssue or problem Referral or action made Referred to




□ Medicare claim 708 completed □ Medicare claim 709 completed □ Medicare claim 711 (RAN/AHW) completed

Name of personcompleting check Signature AHW RN DR Date / /

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under 5s program health - remote health atlasremotehealthatlas.nt.gov.au/hu5k_forms_full_set.pdf ·...

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