Free Detailed Health Assessment Record Template
Detailed Health Assessment Record
I. Purpose of the Assessment
The Detailed Health Assessment Record provides a comprehensive overview of an individual's health status, covering physical, mental, and emotional well-being. This record aims to identify health risks, document current health conditions, and establish a foundation for personalized health interventions.
II. Patient Information
|
Field |
Details |
|---|---|
|
Name: |
Sophia Ramirez |
|
Date of Birth: |
March 8, 2051 |
|
Age: |
4 years |
|
Gender: |
Female |
|
Parent/Guardian Name: |
Elena Ramirez |
|
Contact Number: |
222 555 7777 |
|
Assessment Date: |
April 20, 2055 |
III. Medical History
|
Question |
Response |
|---|---|
|
Any history of chronic illness? |
No |
|
Known allergies? |
Mild peanut allergy |
|
Current medications? |
None |
|
Past surgeries or hospitalizations? |
None |
|
Family history of illness? |
Asthma (father) |
IV. Physical Examination
|
Criteria |
Measurement / Notes |
|---|---|
|
Height: |
40 inches (101.6 cm) |
|
Weight: |
35 lbs (15.9 kg) |
|
Body Mass Index (BMI): |
15.5 |
|
Vision Screening: |
20/30 in both eyes |
|
Hearing Screening: |
Passed |
|
Skin Condition: |
Clear, no abnormalities |
|
Dental Health: |
Mild plaque buildup; no cavities |
|
Respiratory Rate (breaths/min): |
22 |
|
Heart Rate (beats/min): |
98 |
|
Blood Pressure: |
90/60 mmHg |
V. Developmental Assessment
|
Domain |
Observation |
Notes |
|---|---|---|
|
Gross Motor Skills: |
Age-appropriate |
Active and coordinated. |
|
Fine Motor Skills: |
Slight delay |
Struggles with precise movements. |
|
Speech and Language: |
On track |
Speaks in full sentences. |
|
Social Interaction: |
Appropriate for age |
Engages well with peers. |
VI. Immunization Status
|
Vaccine |
Date Administered |
Notes |
|---|---|---|
|
MMR (Measles, Mumps, Rubella) |
March 10, 2054 |
Up to date |
|
DTaP (Diphtheria, Tetanus, Pertussis) |
April 15, 2054 |
Up to date |
|
Polio |
May 20, 2054 |
Up to date |
|
Varicella |
July 18, 2054 |
Up to date |
|
Hepatitis B |
September 22, 2051 |
Completed |
VII. Behavioral and Emotional Health
|
Criteria |
Observation |
Notes |
|---|---|---|
|
Emotional Regulation: |
On track |
Expresses needs verbally. |
|
Attention Span: |
Slightly short for age |
Easily distracted in long tasks. |
|
Sleep Patterns: |
Regular |
10 hours per night. |
|
Appetite: |
Normal |
Eats a balanced diet. |
VIII. Assessment Summary
|
Area |
Status |
Recommendations |
|---|---|---|
|
Physical Health |
Generally good |
Maintain regular dental checkups. |
|
Developmental Milestones |
Slight delay in fine motor skills |
Practice activities like drawing. |
|
Immunizations |
Up to date |
Continue regular schedule. |
|
Emotional and Behavioral Health |
Normal with minor distractions |
Encourage focused activities. |
IX. Recommendations
-
Schedule a follow-up visit in six months for routine checkup.
-
Engage in fine motor skill activities, such as puzzles and coloring.
-
Ensure consistent dental hygiene practices.
-
Provide structured play to improve focus and attention span.
Assessor’s Details:
-
Name: [YOUR NAME]
-
Position: Pediatric Health Evaluator
-
Organization: [YOUR COMPANY NAME]
Acknowledgment:
I, the undersigned, confirm that this health assessment has been conducted to the best of my ability, adhering to the principles of fairness and accuracy.
Signature: ___________________________
Date: April 20, 2055
