Facility:
OUT OF HOME CARE PRIMARY HEALTH SCREEN (2A):
UNDER 1 YR	Surname: <PtSurname>          
Given Name: <PtFirstName>                    
DOB: <PtDoB>              Sex…<PtSex>
Address:<PtAddress> 
Location/ Ward:
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE	
Red flags O  indicate need for further assessment or Comprehensive Health Assessment (2B).	
To assist with the assessment, carers have been requested to complete relevant pages in the NSW Personal
Health Record (“blue book”) and bring this to the appointment	
DETAILS OF THE CHILD	
Country of Birth:  	Preferred Language:  
Interpreter Required:  □ No  □ Yes  Type:	
Refugee No  □ Yes □
	□ Aboriginal                       □ Torres Strait Islander   □ Aboriginal & Torres Strait Islander  
□ Neither Aboriginal nor Torres Strait Islander 	
Biological Family Health History	
Child’s past and present health concerns (including pregnancy and birth information)	
Medications (name, dose frequency, include medication prescribed for neonatal abstinence syndrome O)	
PHYSICAL HEALTH SCREEN	
Immunisation status Up to date ☐ Catch up required ☐ (Include follow-up actions on Health Management Plan)	
Allergies No ☐ Yes ☐ Specify:	
Issues arising from physical health screen	
PHYSICAL EXAMINATION	
Length                                       cm
                                             centile	Weight                                          kg
                                               centile	Head circumference                       cm
                                                   centile	
Growth concerns NO ☐ YES ☐ O	
Oral Health ‘Lift the lip’ check           No Concerns  ☐ Concerns exist ☐ (refer to oral health)
Hearing                                             No Concerns  ☐ Concerns exist ☐ (refer to audiology)
Vision                                                No Concerns  ☐ Concerns exist ☐ (refer to eye specialist)	
Findings on physical examination	
DEVELOPMENTAL HEALTH SCREEN	
Developmental concerns (carer and/or clinician)               No Concerns ☐ Concerns exist ☐
Specify:	
Ages and Stages Questionnaire                                        No concerns ☐   Concerns exist ☐O	
PSYCHOSOCIAL AND MENTAL HEALTH SCREEN	
Ages and Stages: Social and Emotional Questionnaire    No concerns ☐   Concerns exist ☐O	
Relationship to carer:                                                         No concerns ☐   Concerns exist ☐O	
Emotional development (sleep, routines, settling, crying, feeding, separation issues)
                                                                                           No concerns ☐   Concerns exist ☐O	
CARER CONCERNS REGARDING PLACEMENT	
Carer wellbeing and capacity to meet the needs of the child/young person
                                                                                           No concerns ☐   Concerns exist ☐O	
COMPREHENSIVE ASSESSMENT REQUIRED             YES ☐ Referral made to:
                                                                     NO ☐ If no, please complete Health Management Plan (SMR060.720 (NH606661))	
Assessment completed by:
(Name and designation)<DrName>	Signature: 	Date:<TodaysDate>