Free Detailed Health Assessment Record Template

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Free Detailed Health Assessment Record Template

Detailed Health Assessment Record

Patient Information

Field

Details

Name:

Date of Birth:

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

Immunizations

Emotional and Behavioral Health

Recommendations


Assessor’s Details:

Physician's Signature

Licensed Number:


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