Form 1 Health Assessment Form

Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB

Health Assessment Form (Clean)

Health Assessment Form

OMB: 0970-0509

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Shape4 OMB Control No: 0970-0509

Expiration date: XX/XX/XXXX


Health Assessment Form

Unaccompanied Children’s Program

Office of Refugee Resettlement (ORR)

General Information

Minor

Last name:

First name:

DOB:

A#:

Gender:

Healthcare Provider (HCP)

Name:

MD / DO / PA / NP

Clinic/Practice:

Specialty Type:

Street address:

City or Town:

State:

Phone number:

Location where child received care (e.g., Offsite clinic, ER):

Date evaluated:

Program

Program name:

  • Program Staff Member Present During Exam with HCP

History and Physical Assessment

Vital Signs

Temperature (T)

Heart Rate (HR)

BP (> 3 yrs)

Resp Rate (RR)

Height (HT)

Weight (WT)

BMI (>2 yrs)

BMI %ile

F / C




in / cm


lbs / kg



Allergies:

  • No

  • Yes, specify below


Food

Medication

Environmental

Other

Allergen





Reaction





Medical History

Concerns Expressed by Minor or Caregiver:



Review of Systems (ROS) and Physical Exam

Were any signs/symptoms reported by the minor or observed by program staff or HCP?

  • No

  • Yes, check all applicable signs/symptoms and enter the onset date (mm/dd/yyyy):

Sign/Symptom

  • Pain, location:

_____________

  • Fever (>37.8 Co) or chills

  • Red Eyes

  • Runny Nose

  • Sore Throat

  • Cough

  • Difficulty breathing/ Shortness of Breath

Onset Date








Sign/Symptom

  • Nausea

  • Vomiting

  • Diarrhea

  • Neck stiffness

  • Headache

  • Dizziness

  • Confusion/Altered mental status

Onset Date








Sign/Symptom

  • Neurologic symptoms

  • Skin lesions/Rash

  • Yellow skin/eyes

  • Swollen glands

  • Unusual bleeding

  • Other: ___________

  • Other: _________________

Onset Date








Physical exam performed by HCP:

  • No

  • Yes, enter the findings for each evaluated system

System

Evaluated, Findings

Describe findings

General appearance

  • Normal

  • Abnormal


HEENT

  • Normal

  • Abnormal


Neck

  • Normal

  • Abnormal


Heart

  • Normal

  • Abnormal


Lungs

  • Normal

  • Abnormal


GU/GYN

  • Normal

  • Abnormal


Extremities

  • Normal

  • Abnormal


Abdomen

  • Normal

  • Abnormal


Back/Spine

  • Normal

  • Abnormal


Neurologic

  • Normal

  • Abnormal


Skin (include tattoos)

  • Normal

  • Abnormal


Other _____________

  • Normal

  • Abnormal


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Laboratory Testing

Condition

Indicators

Test

Result

Influenza

Fever + cough or sore throat

  • Rapid flu

  • Negative

  • Positive, type:

  • A

  • B

  • A/B

  • Unk

Strep throat

Sore throat + fever without cough

  • Rapid strep

  • Negative

  • Positive

Lead

Previously elevated lead level

  • Capillary, Lead

  • Ordered/Pending

  • Negative

  • Positive (>5 mcg/dl), level: ___

  • Blood/Serum, Lead

  • Ordered/Pending

Pregnancy

­Sexual activity

  • Urine pregnancy

  • Negative

  • Positive

  • Indeterminate

  • Blood/Serum hCG

  • Ordered/Pending

HIV

Sexual activity

  • Rapid oral

  • Negative

  • Positive

  • Indeterminate

  • Blood/Serum, 4th Gen

  • Ordered/Pending

Chlamydia

Sexual activity

  • NAAT/PCR

  • Ordered/Pending

Gonorrhea

Sexual activity

  • NAAT/PCR

  • Ordered/Pending

Syphilis

Sexual activity

  • RPR/VRDL

  • Ordered/Pending

Hepatitis B

Sexual activity or Injection drug use

  • Surface antigen

  • Ordered/Pending

Hepatitis C

Injection drug use

  • Antibody, Total

  • Ordered/Pending

Active

Tuberculosis

Active TB Work Up

  • AFB smear

  • TB culture

  • NAAT/PCR

  • MDDR

  • DST

  • Ordered/Pending

  • Ordered/Pending

  • Ordered/Pending

  • Ordered/Pending

  • Ordered/Pending

Other Reportable Infectious Disease:



Specify:

  • Ordered/Pending

Diagnosis and Plan

Diagnosis:

Minor with new complaints, symptoms, diagnoses/conditions; meds prescribed (including OTC) or referrals needed:

  • No, specify reason for exam (e.g., follow-up immunizations): ___________________________________________________________

  • Yes, check all diagnoses that apply below. Specify in the space provided, where indicated.

General/Constitutional

  • Anemia

  • Allergy (e.g., drug reaction, food allergy): ________________________

  • Dehydration

  • Lead poisoning

  • Lymphadenopathy

  • Malnourished

  • Pallor

  • Other: _______________________________________________________________________________________________________________________

HEENT

  • Conjunctivitis

  • Eyelid lesions

  • Otitis media/externa

  • Rhinitis

  • Hearing issues: ___________________________

  • Speech impediment

  • Strep throat

  • Pharyngitis (Not strep throat)

  • Vision issues: ____________________________

  • Other: ____________________________________________________________________________

Respiratory/Pulmonary

  • Asthma

  • Chronic cough

  • Abnormal CXR (Non-TB): ___________

  • Lower respiratory illness: __________________

  • Upper respiratory illness: _________________________

  • Influenza-like illness (ILI)

  • Influenza, lab-confirmed: __________________

  • Other: ____________________________________________________________________________

Cardiovascular

  • Arrhythmia

  • Elevated blood pressure

  • Chest pain

  • Heart murmur

  • Syncope/fainting

  • Congenital heart disease: _____________________________________________________________

  • Acquired heart disease: ____________________

  • Other: ____________________________________________________________________________

Endocrine Disorder

  • Diabetes, Type 1 and 2

  • Hyper/Hypothyroidism

  • Delayed/Precocious puberty

  • Other: ________________________________________________________________________________________________________________________

Gastrointestinal

  • Abdominal pain

  • Constipation

  • Celiac disease

  • Diarrhea, Acute/Chronic

  • Failure to thrive

  • Gastritis/Peptic ulcer

  • Gastroenteritis

  • GI bleeding

  • Heartburn/Reflux

  • Jaundice

  • Liver disease

  • Weight loss

  • Inflammatory bowel disease

  • Intestinal parasites: _________________________________

  • Other: ________________________________________________________________________________________________________________________

Genito-urinary/Reproductive

  • Bed-wetting

  • Hematuria

  • Proteinuria

  • Inguinal hernia

  • Kidney stones

  • Urinary tract infection

  • Testicular torsion

  • Hydrocele/Varicocele

  • Abnormal Vaginal Bleeding/Discharge

  • Amenorrhea/Dysmenorrhea /Menorrhagia

  • Gynecomastia/Breast Mass (fibroadenomas, cysts)

  • Genital warts

  • Pelvic Inflammatory Disease

  • Pregnant: Current gestational age _____ wks, Est. due date __/__/____

  • Childbirth

  • Spontaneous abortion

  • Elective abortion

  • Consensual sexual activity, who/when/where: _________________________

  • Other: ___________________________________________________

Neurological

  • Brain tumor

  • Cerebral palsy

  • Cerebrovascular disease

  • Cognitive disorder / IQ deficit

  • Developmental delay

  • Headache/Migraine

  • Neurocysticercosis

  • Traumatic brain injury / Concussion

  • Seizure/Epilepsy

  • Other: ____________________________________________________

Musculoskeletal

  • Back pain

  • Extremity/Joint pain

  • Bone tumors (benign/malignant)

  • Fracture

  • Sprain/Strain

  • Scoliosis/Kyphosis

  • Ligamentous/Tendon injury

  • Other: ________________________________________________________________________________________________________________________

Skin, Hair, and Nails

  • Acne

  • Atopic dermatitis/Eczema

  • Allergic/Irritant Contact Dermatitis

  • Lice

  • Scabies

  • Ingrown toenail

  • Acanthosis Nigricans

  • Hair loss/Allopecia Areata

  • Cellulitis

  • Ringworm

  • Tattoos

  • Tinea pedis

  • Onychomycosis

  • Scars

  • Warts

  • Other: ____________________________________________________________________________

Potentially Reportable Infectious Disease

  • Acute hepatitis A

  • Acute/chronic hepatitis B

  • Acute/chronic hepatitis C

  • Chikungunya

  • Chlamydia

  • COVID-19

  • Dengue

  • Gonorrhea

  • HIV

  • Malaria

  • Measles

  • Mumps

  • Pertussis

  • Rubella

  • Sepsis/Meningitis

  • Syphilis

  • TB, active disease

  • TB, latent (LTBI)

  • Typhoid fever

  • Varicella

  • Zika virus

  • Viral hemorrhagic fever: ______________________________________

  • Other: ________________________________________________________________________________________________________________________

Medical, Other




Behavioral and Mental Health Concerns

  • ADHD/ADD

  • Adjustment disorder

  • Autism

  • Bipolar disorder

  • Conduct disorder

  • Depressive disorder

  • Borderline personality disorder

  • Generalized Anxiety disorder

  • Eating disorder

  • Hallucinations

  • Panic disorder

  • Obsessive-Compulsive Disorder

  • Oppositional Defiant Disorder

  • PTSD

  • Schizophrenia

  • Self-injury/cutting

  • Separation anxiety disorder

  • Suicide ideation/attempt

  • Nonconsensual sexual activity, who/when/where: ______________________

  • Other: ___________________________________________________

Dental

  • Broken tooth or teeth

  • Gingivitis/gum disease

  • Impacted tooth/teeth

  • Infection/abscess

  • Tooth decay/caries

  • Tooth sensitivity

  • Other: _______________________________________________

Plan: Check all that apply and specify where indicated. Please provide copies of office notes, lab/imaging results, and immunization records to program staff.

Return to clinic:

  • PRN/As needed


  • Follow-up (specify condition, timing): ________________________________________________________________________

Minor fit to travel:

  • No

  • Yes: _______________________________________________________________________________________________

Per program staff, discharge from ORR custody will be delayed:

  • No

  • Yes: _________________________________________________________

Minor has/may have an ADA disability:

  • No

Yes: _________________________________________________________________________________

  • Referred to specialist: __________________________________________________________________________________________________________

  • Minor requires quarantine/isolation, specify diagnosis and timeframe: ___________________________________________________________________

  • Medications (specify name, reason, date started, dose, and directions and indicate if psychotropic):

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

  • Immunizations given

  • List immunizations that were indicated, but not given and state why: ____________________________________________________________________

____________________________________________________________________________________________________________________________

  • Age-appropriate anticipatory guidance discussed and/or handout given

  • Surgery/procedure needed/performed:____________________________________________________________________________________________

  • Physical/dietary restrictions:_____________________________________________________________________________________________________

  • Visiting nurse services required: __________________________________________________________________________________________________

  • Physical/Occupational/Speech therapy required: ____________________________________________________________________________________

  • Durable medical equipment required: _____________________________________________________________________________________________

  • Per local/state reporting guidelines, Health Department was notified of suspect/confirmed diagnosis of a reportable infectious disease

Were other minors in ORR custody potentially exposed during infectious period?

  • No

  • Yes

Grantee staff members at shelter potentially exposed, how many? ________

  • Other:

Recommendations from Healthcare Provider / Additional Information










Healthcare Provider Signature: ______________________________________________________________ Date: _______ / ______ / __________


Healthcare Provider Printed Name: ___________________________________________________________



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The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 9 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0509 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact UACPolicy@acf.hhs.gov.




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBuckley, Kirsten (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2021-01-13
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