Facility:

OUT OF HOME CARE PRIMARY HEALTH SCREEN (2A):
12 -18 YEARS	Surname: <<Patient Demographics:Surname>>          
Given Name: <<Patient Demographics:First Name>>                    
DOB: <<Patient Demographics:DOB>>              Sex…<<Patient Demographics:Sex>>
Address:<<Patient Demographics:Full Address>> 
Location/ Ward:
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE	
Red flags O  indicate need for further assessment or Comprehensive Health Assessment (2B).	
Carers are asked to bring a completed the Strengths and Difficulties Questionnaires (SDQ) to the appointment.	
DETAILS OF THE CHILD/YOUNG PERSON	
Country of Birth:  <<Patient Demographics: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/Young person'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	
Physical development/growth concerns              NO ☐                 YES ☐ O
Specify:	
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 (School, academic, employment, cognitive development, activities of daily living)               Within normal limits ☐ Concerns exist ☐O
Specify:	
PSYCHOSOCIAL AND MENTAL HEALTH SCREEN
Consider using HEEADSSS assessment tool http://www.caah.chw.edu.au/resources/gpkit/19_Appendix_2.pdf
H - Home                                                                 No concerns ☐ Concerns exist ☐
E - Education, Employment                                  No concerns ☐ Concerns exist ☐
E - Eating, Exercise                                                No concerns ☐ Concerns exist ☐
A - Activities, Hobbies & Peer Relationships       No concerns ☐ Concerns exist ☐
D - Drug Use                                                            No concerns ☐ Concerns exist ☐O
S - Sexual Activity & Sexuality                               No concerns ☐ Concerns exist ☐O
S - Suicide, Depression & Mental Health              No concerns ☐ Concerns exist ☐O
S - Safety                                                                  No concerns ☐ Concerns exist ☐O	
Kessler 10 Score 16 or above (med/high risk)                                   No ☐                     Yes ☐O	
History of violence or aggression:                                      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)<<Doctor:Name>>	Signature: 	Date:<<Miscellaneous:Date (short)>>