ATCAA Early Head Start/Head Start/State Preschool/General Child Care

427 N. Highway 49, Suite 305, Sonora, CA 95370 · 209-533-0361 · Fax 209-533-0470

Name of Child DOB Class

TO BE COMPLETED BY MEDICAL PROVIDER MEDICAL EXAMINATION REPORT

Check One: / 1 mo / 2 mo / 4 mo / 6 mo / 9 mo / 12 mo / 18 mo / 2 yrs / 3 yrs / 4 yrs / 5 yrs / Other
Date of Exam: _____ / _____ / _____ / Done
(Results) / Not Done / Concerns / Explanation of Concerns or
Comments / Recommendations /
History / Physical Exam / *Required annually to attend Early Head Start, Head Start
Dental Assessment
Fluoride Prescribed? Yes_____ No______/ *
Nutritional Assessment / *
Health Education (Anticipatory Guidance) / *
Developmental Assessment / * /
( ) Enrolled in WIC ( ) Referred to WIC
Tobacco Assessment
Patient is exposed to passive (second hand) smoke? YES NO
Patient uses tobacco? YES NO
Counseled about / referred for tobacco use YES NO
prevention / cessation?
Vision Assessment (under 3 yrs old) / *
Vision Screen (3 yrs & up) / *OU______
Hearing Assessment (under 3 yrs old) / *
Hearing Screen (3 yrs & up) / *
Hemoglobin or Hematocrit required by Head Start @ 7-9 m, 13-15 m & 2, 3, 4, 5 yrs / *Value______
Urinalysis or Dipstick
Blood Pressure/Head Circumference / *_____ / _____
Height / Weight / *Ht.
*Wt.
Blood Lead Test required @ 12 & 24 mos (up to 72 mos if not previously tested)
Result required by Head Start. / *
TB Risk Assessment *( ) At risk-skin test
( ) Risk factors not present--no skin test / Test Result:
( ) Neg. ( ) Pos.
TB risk factors for children / Immunizations / Given Today / Refused or Contraindicated
Have a family member or contacts with a history of confirmed or suspected TB.
Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central & South America)
Live in out –of-home placements
Have, or are suspected to have, HIV infection
Live with an adult with HIV seropositivity
Live with an adult who has been incarcerated in the last five years
Live among, or are frequently exposed to individuals who are homeless, migrant farm workers, users of street drugs or residents in nursing homes.
Have abnormalities on chest x-ray suggestive of TB
Have clinical evidence of TB / Child up to date? ( ) Yes ( ) No
Physician’s Signature / Please Return to Parent After
Exam or Mail / Fax to the Above
Address – Thank you
Physician’s Name (Please Print)