Facility:

OUT OF HOME CARE PRIMARY HEALTH SCREEN (2A):
6 -11 YEARS	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 	
Medications (name, dose frequency, include medication prescribed for emotional or behavioural issues 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	
Height                           cm                                   centile	Weight                      kg
                           centile	Head                                       cm
circumference                   centile	BMI	
Growth concerns NO ☐ YES ☐ O	
Oral Health annual check?               Completed      ☐ Referral required ☐ 
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 (Language, play skills, gross motor, fine motor, self-help, cognitive skills)                  Within normal limits ☐ Concerns exist ☐O
Specify:	
PSYCHOSOCIAL AND MENTAL HEALTH SCREEN	
Mental health diagnosis present?                                                       No ☐                     Yes ☐O	
Relationship issues:                                                           No concerns ☐   Concerns exist ☐O	
School/academic issues:                                                   No concerns ☐   Concerns exist ☐O	
Child in a residential care placement?                                                No ☐                     Yes ☐O	
EMOTIONAL DEVELOPMENT/BEHAVIOURAL CONCERNS (Anxious, aggressive, emotional regulation issues)
                                                                                           No concerns ☐   Concerns exist ☐O	
CARER CONCERNS REGARDING PLACEMENTCarer wellbeing and capacity to meet the needs of the child/young person                                                             No concerns ☐   Concerns exist ☐O	
STRENGTHS AND DIFFICULTIES QUESTIONNAIRE: Complete results at http://www.sdqscore.org/
                                                  Clinically significant difficulties    No ☐                     Yes ☐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>