Health Assessment of the School-Age Child (5-12 Years)

The Worksheet

All children should have a yearly health maintenance visit. By six years of age, most children can provide reasonably accurate medical information, and it is a good idea to talk to the child as well as to the parent.

If this is patient is new to you, obtain the complete family medical and social history. Use the School-Age Child Health Maintenance guide to complete the age-related history and physical examination.

Click on the highlights below for more detail or to branch to a hyperlink within the popup. You can get to a print version of the form on the side bar.

 

Interim History since last well child visit:

 

Concerns to discuss today:

OLD CARTS, present history in logical, chronological order

 

Review Past Medical History/Family Medical History (PMH/FMH):

Include appropriate information, including dates of hospitalizations/surgeries if possible, ages/illnesses of relatives

 

Medications:

Include names, dosages, and frequencies of prescription, over-the-counter, and alternative therapies

 

Allergies:

Include drug, food, and environmental allergies and patient's reaction

 

Social History:

Include who lives at home, who cares for the child/daycare, smoke exposure, pets

 

Nutritional Assessment:

 

Liquid intake: (water/milk/other such as juice and sugary drinks)
Food groups consumed:
Discuss portion sizes:

Snack choices

 

Urination:

Stooling:

 

Parent concerns regarding nutrition

Mental Health Assessment:

Include: Sleep, Family stresses, Parenting needs, Child abuse risk, Behavior challenges

 

Developmental Assessment:/Ages and Stages Questionnaire:

School performances, Extra curricular activities, Communication effectiveness (verbal/written), Interpersonal relationships

Review of Systems:
Physical Exam:

 

Vital Signs:

Weight (percentile):_______,____%
Length(percentile):_______,____%

BMI: :_______,____%

Temperature:_________
Pulse:__________
Respiratory rate:________
Blood pressure:_________

General appearance
Head
Eyes
Ears
Nose
Mouth and Teeth

Oropharynx
Neck/nodes
Respiratory

Cardiovascular

Abdominal

Genitalia

Musculoskeletal/hips
Neurologic/reflexes

Skin

Other

Screening:

Vision,Hearing, Hemoglobin, Tuberculosis questionnaire, Dental screening

 

Health Education/Anticipatory Guidance:

Nutritian: Growth charts, Healthy diet

Safety: Smoke detectors, Car seats/booster seats, Ingestions, Choking, Stranger safety, Internet safety, Firearms

Health Promotion: Immunizations,Tobacco exposure, Med. Resource Use, Limit screen time, Monitor screen content

Family: Siblings, Address concerns

Immunizations indicated today:

Labs (hemoglobin/lipids/other) indicated today:

 Based on screening and Texas Health Steps recommendations

Next Well Check :

 

Quickchecks: Developmental Milestones

 Quiz Group  

 

 

 


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