Free Detailed Health Assessment Record Template
Detailed Health Assessment Record
Patient Information
Field |
Details |
---|---|
Name: |
|
Date of Birth: |
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Age: |
|
Gender: |
|
Parent/Guardian Name: |
|
Contact Number: |
|
Assessment Date: |
Medical History
Question |
Response |
---|---|
Any history of chronic illness? |
|
Known allergies? |
|
Current medications? |
|
Past surgeries or hospitalizations? |
|
Family history of illness? |
Physical Examination
Criteria |
Measurement / Notes |
---|---|
Height: |
|
Weight: |
|
Body Mass Index (BMI): |
|
Vision Screening: |
|
Hearing Screening: |
|
Skin Condition: |
|
Dental Health: |
|
Respiratory Rate (breaths/min): |
|
Heart Rate (beats/min): |
|
Blood Pressure: |
Developmental Assessment
Domain |
Observation |
Notes |
---|---|---|
Gross Motor Skills: |
||
Fine Motor Skills: |
||
Speech and Language: |
||
Social Interaction: |
Immunization Status
Vaccine |
Date Administered |
Notes |
---|---|---|
MMR (Measles, Mumps, Rubella) |
||
DTaP (Diphtheria, Tetanus, Pertussis) |
||
Polio |
||
Varicella |
||
Hepatitis B |
Behavioral and Emotional Health
Criteria |
Observation |
Notes |
---|---|---|
Emotional Regulation: |
||
Attention Span: |
||
Sleep Patterns: |
||
Appetite: |
Assessment Summary
Area |
Status |
Recommendations |
---|---|---|
Physical Health |
||
Developmental Milestones |
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Immunizations |
||
Emotional and Behavioral Health |
Recommendations
Assessor’s Details:
Physician's Signature
Licensed Number: