www.nt.gov.au/health
Under 5s Program
January 2009
Child History
First Name
Ethnicity
Surname
(circle)
1. AB
Known as
DOB
/
Address
HRN
Other communities visited often
Medicare Number
Other name
Mother
Grandmother Aunty Other
Carer’s name
(Specifiy)
Who supports carer at home?
Language used at home
Key family members
Brothers’/sisters’ names
Mother’s
HRN
Place of birth - RDH DPH ASH
Mode of birth
Important family history
KH
TCH GDH
Date discharged
Other (name)
NVB
Breech
Birth
weight
Caesarian
Vacuum Forceps
Discharge
weight
Birth
length
Newborn exam completed?
Yes No
Neonatal Screening?
Yes No
Neonatal Hearing Screen?
Yes No
Follow up Hearing screen needed?
Yes No
Breast Feeding at hospital discharge?
Yes
No
Syphilis serology needed? Yes
No
Hep B serology needed?
Yes
No
APGAR
1min
Gestation
Head
Circ
Problems with Breast Feeding
Added to recall?
List any maternal complications
/
5min
Birth vaccines given
Yes
No
List any birth/neonatal problems/abnormalities (add to recall as needed)
Breast Feeding
Exclusively?
Yes No
Yes
/
Obstetric and birth history
(Circle)
Father’s name
N/A
No
Main carer:
/
Family details
Mother’s name
2. TSI 3. TSI/AB 4 not AB/TSI 5. Unknown
Child details
Midwife, Child Health Nurse, RAN, AHW to complete
Added to recall?
Yes No
FOLLOW UP APPOINTMENTS POST DISCHARGE
Problem
Appointment with
Place follow up
Date follow up
General comments
Name of person
completing history
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Signature
AHW RN
Date
/
/
Child History
1
www.nt.gov.au/health
Under 5s Program
January 2009
Risk Assessment
Midwife, Child Health Nurse, RAN, AHW to complete
For all children tick boxes that match identified risk factors
To be completed by the 8 week check or for any new child to community
The purpose of completing the Risk Assessment is to identify children and families who may require additional support
If any of these risk factors are present:
1. Discuss with the primary carer and develop a care plan if needed
2. Domestic or family violence contact other services for support
3. Mental health/substance misuse contact other services for support
4. Provide brief intervention for any identified problems
Children and families who need close support and follow up by the Primary Health Care Team at the health centre
AND review by the visiting paediatrician (add to recall)
Low birth weight (<2,500 gms)
Known disability or illness
Premature birth (<37 weeks)
Siblings with malnutrition or FTT
Difficult birth or neonatal problems/illness
Siblings notified to NT Families and Children (FACS)
Twins or triplets
History of alcohol or drug use in pregnancy
General comments
Children and families who need close support and follow up by the Primary Health Care Team at the health centre
First time or young mother
Lack of social support/isolation
Single mother
Domestic and/or family violence
Mother or care with disability
Gambling
Other children in family with disabilities
Financial stress (can’t meet basic family needs)
Mental Health issues of parents/carer including PND
Recent family stress
(eg. deaths or serious illness in family)
Substance use in immediate family
Action Required
Yes
No
Alcohol
Details:
Marijuana
Other (specify)
Prompt for “Added to recall”
Yes
No
General comments
Name of person
completing history
2
Signature
Risk Assessment
AHW
RN
Date
/
/
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/health
Under 5s Program
January 2009
First Assessment
Midwife, Child Health Nurse, RAN, AHW to complete
Discussion points are in a black box. Tick as completed
First Name
DOB
/
/
Child history completed? Yes
Age (Weeks)
Date Review
Carer attending
Any current concerns? (ask about general health, crying, sleeping)
Weight
/
/
Plotted on growth chart? Yes
Weight gain since discharge from hospital?
Significant illnesses at time of review
No
No
Yes
No
Is the weight gain sufficient?
Yes
No
Signs of bonding/attachment present?
Yes
No
Umbilicus healing?
Yes
No
(close contact, eye contact, concern, care, pride) If no consider referral for support
Any concerns about feeding?
Since this time yesterday has the baby had
Formula
Nutrition
Postnatal issues for mother?
(Refer to Women’s Business Manual)
Breast milk
General check
Surname
Child details
HRN
Other milk
Other (specify)
BREAST FEEDING is best for baby - encourage exclusive breast feeding
ORAL HEALTH Healthy mouth for baby starts with mothers good oral health. Bad germs can go from your mouth to baby’s
mouth in your spit. Remember to brush your teeth twice a day with fluoride toothpaste and visit the dentist for a check
HYGIENE Bath the baby regularly - at least every second day and wash your hands after changing nappies
SIDS PREVENTION To help keep baby safe when sleeping, lie baby on back in clean flat place. Keep baby cool. Don’t wrap too
tightly - make sure baby’s head and arms are free to move. Don’t share the bed with baby if you or your husband or boyfriend
have been drinking grog, smoking gunja or using other drugs. Keep the baby away from cigarette and campfire smoke.
INJURY PREVENTION Car seats and seat belts protect kids AND adults in the car
Are there any urgent housing repairs?
Does anyone smoke in the house or car
If yes consider brief intervention (SNAPE)
Children
Yes
No
Yes
No
Action taken:
Home
Number of people living in the house: Adults
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the
screen, ensure privacy and reassure them that all people are asked the same questions. Offer to follow up and support mother/carer with
any problems identified.
Was DFV screen done at this visit?
Yes
No
Referral made
Yes
No
Use S&E Assessment form
Action and follow up
Issue or problem
Referral or action made
Referral to
MO
Paed Other (specify)
MO
Paed Other (specify)
MO
Paed Other (specify)
General comments
□ Prompt for 8 week check
□ 2nd Weekly recall for GAA
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
Signature
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
AHW
RN
Date
/
/
First Assessment
3
www.nt.gov.au/health
Under 5s Program
January 2009
8 Week Assessment
Midwife, Child Health Nurse, RAN, AHW and MO to complete
Discussion points are in a black box. Tick as completed
First Name
Surname
DOB
/
/
Child history completed?
Age (Weeks)
Date Review
Carer attending
/
Yes
Child details
HRN
No
/
Any current concerns (ask about general health, crying, sleeping)
Significant illnesses at time of review
Any concerns about hearing?
Yes
No
Any concerns about vision?
Yes
No
Any concerns about general development?
Yes
No
Signs of bonding/attachment present?
Yes
No
General check
Problems Identified at previous check:
(close contact, eye contact, concern, care, pride) If no consider referral for support
Has the mother had her Post Natal Check (PNC)?
Yes
No
(If no refer to midwife or DMO and consult WBM)
Complete head lag
Not following with eyes
Not smiling
Baby very floppy or stiff
Does not startle at loud
noises
Family concerns
Development
DEVELOPMENTAL POINTERS
At eight weeks babies should be smiling at carer and responsive to loud sounds. They should be able to fix on and follow a face.
They should be developing some head control when pulled to sit.
If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Comments about development
COMMUNICATE Look into your baby’s eyes and smile at him/her. Breast feeding is a good time to do this
BREAST FEEDING Is best for baby - encourage exclusive breast feeding. Babies do not need anything but breastmilk
ORAL HEALTH Healthy mouth - starts with mother’s good oral health. Bad germs can go from your mouth to baby’s
mouth in your spit. Remember to brush your teeth twice a day with fluoride toothpaste and visit the dentist for a check
Since this time yesterday has the baby had
Formula
Other milk
Tea
Water
Nutrition
Breast milk
Any concerns about feeding?
Soft drink/cordial/fruit juice
(these can damage teeth)
Other (specify)
HYGIENE Bath baby regularly - at least every second day. Wash your hands after changing nappies. Keep baby’s and other
children’s face and hands clean to stop germs from pus affected ears and noses spreading
SIDS PREVENTION To help keep baby safe when sleeping, lie baby on back in clean flat place. Keep baby cool. Don’t wrap too
tightly - arms are free to move. Don’t share the bed with baby if you or your husband or boyfriend have been drinking grog, smoking
marijuana or using other drugs. Keep the baby away from cigarette and campfire smoke
INJURY PREVENTION Car seats and seat belts protect kids AND adults in the car
Adults
Are there any urgent housing repairs?
Yes
Children
Does anyone smoke in the house/car?
If yes consider brief intervention (SNAPE)
No
Housing referral made?
Yes
Yes
No
No
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to. If the mother/carer agrees to the
screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Was DFV screen done at this visit?
Yes
No
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Referral made
Yes
No
Home
Number of people living in the house:
Use S&E Assessment form
8 Week Assessment
4
www.nt.gov.au/health
Under 5s Program
January 2009
8 Week Examination
Yes
No
Yes
No
Head Circ.
Length
Fontanelles
Skin
Action Plan needed?
Plot on growth chart
Clear
AF
Scabies
Open
Sores
PF
Closed
Ringworm
2 month immunisation given?
□ Yes
□ Already □ This visit (Record on immunisation sheet)
□ Unable to give - place on recall
R ear
Other (specify)
L ear
Treatment
Open
Closed
Examination
Weight gain satisfactory?
Weight
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
CVS
Heart sounds
Femoral pulses present?
Normal
Abnormal
Yes
No
R hip
Normal
Abnormal
L hip
Normal
Abnormal
R testis descended
Yes
No
L testis descended
Yes
No
Medical Officer Examination
Treatment
General appearance and comments
Action and follow up
Make a note on the 4 month form of any problems that need follow up
Issue or problem
Referral or action made
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
General comments
□ Prompt for 4 month check
□ Medicare claim 708 completed
□ Monthly recall for GAA
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
5
Signature
8 Week Examination
AHW
RN
DR
Date
/
/
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/health
Under 5s Program
January 2009
4 Month Assessment
Child Health Nurse, RAN or AHW to complete
HRN
Surname
Date Review
DOB
/
/
4 month immunisation given?
/
□ Already □ This visit
/
(Record on immunisationsheet)
Carer attending
Age (Weeks)
□ Yes
Child details
Discussion points are in a black box. Tick as completed
First Name
□ Unable to give - place on recall
General check
Problems identified at previous check:
Any current concerns?
(general health, crying, sleeping)
Significant illnesses at time of review:
Scabies
Action required?
No
Sores
No
Details:
Ringworm
R ear
Other (specify)
L ear
Treatment
Yes
No
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
Examination
Yes
Clear
Yes
(close contact, eye contact, concern, care, pride) If no consider referral for support
Is growth following curve?
Weight
Skin
Signs of bonding/attachment present?
Nutrition
Treatment
Since this time yesterday has the baby had
Breast milk
Formula
Other milk
Tea
Water
Soft drink/Cordial/Fruit juice
Other (specify)
(these can damage teeth)
BREAST FEEDING Is best for baby - encourage exclusive breast feeding. Wait until 6 months before starting solid food
HYGIENE Keep baby’s face and hands clean to stop germs spreading from pus affected ears and runny noses. Bath baby
regularly- at least every second day. Wash hands after changing nappies. Use tissue spears to clean ears. Keep baby away from
smoke to reduce the risk of ear disease
SIDS PREVENTION To help keep baby safe when sleeping, lie baby on back in clean flat place. Keep baby cool. Don’t wrap too tightly
so arms are free to move. Don’t share the bed with baby if you or your husband or boyfriend have been drinking grog, smoking
marijuana or using other drugs. Keep the baby away from cigarette and campfire smoke
PLAY Let baby have play time on tummy every day
COMMUNICATE Talk to your baby and get a conversation going with sounds or gestures
Was DFV screen done at this visit?
Yes
No
Referral made
Yes
No
Home
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to.
If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Use S&E Assessment form
Action and follow up
Make a note on the 6 month form of any problems that need follow up
Issue or problem
Referral or action made
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
□ Prompt for 6 month check
□ Monthly recall for GAA
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
Signature
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
AHW
RN
DR Date
/
4 Month Assessment
/
6
www.nt.gov.au/health
Under 5s Program
January 2009
6 Month Assessment
Child Health Nurse, RAN or AHW to complete
HRN
Surname
Date Review
DOB
/
/
/
Child details
Discussion points are in a black box. Tick as completed
First Name
/
Carer attending
Age (Weeks)
Any current concerns? (ask about general health, crying, sleeping)
Significant illnesses in last 6 months?
Any concerns about hearing?
Yes
No
Any concerns about vision?
Yes
No
Any concerns about general development?
Yes
No
Signs of bonding/attachment present?
Yes
No
General check
Problems Identified at previous check:
(close contact, eye contact, concern, care, pride) If no consider referral for support
DEVELOPMENTAL POINTERS
At this age babies are laughing and interacting with their families. At 6 months, babies should be able to make eye contact and follow a
person with their eyes. They should be able to turn their heads to familiar voices and sounds and make baby sounds. They roll from front to
back and back to front. They reach for objects using both hands and are starting to transfer objects from one hand to the other
If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Not turning head to soft voice
Squint
Not interested in people
Family concerns
Development
Preference for one hand
Comments about development
Is the child attending playgroup/early childhood development activities on a regular basis?
Yes
No
NA
PLAY Give your child safe household things to handle, bang and drop
COMMUNICATE Respond to your baby’s sounds and interests. Tell your baby the names of things and people
HYGIENE Keep baby’s face and hands clean to stop germs spreading from pus affected ears and runny noses. Bath baby regularlyat least every second day. Wash hands after changing nappies. Use tissue spears to clean ears. Make sure area is clean and safe
for baby
INJURY PREVENTION Because baby is rolling now, be careful putting them up high or leaving them near fires - baby may fall off
ledges or roll into fires
NUTRITION It’s time to start giving your baby solids. Keep breast feeding. (Use NT infant feeding guidelines to show recommended
foods and fluids as shown in ‘A story about feeding babies’ Include quantity, times per day and food safety issues.)
Formula
Has the baby started on solids?
Other milk
Yes
Number of people living in the house:
Tea
No
List (if yes)
Adults
Are there any urgent housing repairs?
Water
Yes
Children
No
Soft drink/Cordial/Fruit juice
Other (specify)
Does anyone smoke in the house/car?
If yes consider brief intervention (SNAPE)
Yes
No
Housing referral made?
Yes
No
(these can damage teeth)
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to.
If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Was DFV screen done at this visit?
Yes
No
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Referral made
Yes
No
Home
Breast milk
Nutrition
Since this time yesterday has the baby had
Use S&E Assessment form
6 Month Assessment
7
www.nt.gov.au/health
Under 5s program
January 2009
6 Month Examination
Child Health Nurse, RAN or AHW to complete
Weight
Weight gain satisfactory?
Yes
Action Plan needed?
No
Yes
No
Plot on growth chart
Length
Skin
Hb
Clear
Scabies
□ Already □ This visit (Record on immunisation sheet)
□ Unable to give - place on recall
Routine de-worm?
Yes
(Refer to CARPA STM)
Rx (low Hb)
Sores
Ringworm
R ear
Other (specify)
L ear
Treatment
□ Yes
6 month immunisation given?
No
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
Recurrent episodes (3 or more) of otitis media?
Yes
No
Oral health
“lift the lip” and check for colour changes in baby’s teeth - white, brown or black spots
Spots seen?
Yes
No
Referred to dental therapist?
Referred to dentist?
General appearance and comments
Yes
Yes
Examination
Treatment
No
No
Chest
□ Persistent cough > 4 weeks
□ Recurrent prolonged wet cough
□ 2 episodes hospitalisation - resp. illness in last 12 months
□ 3 episodes hospitalisation - resp. illness since birth
If yes to any, refer for medical review and record below
ORAL HEALTH Start caring for baby’s new teeth when they first come through. Clean with a damp clean cloth (don’t use
toothpaste until 18 months). Check teeth and gums regularly for any colour changes. It is important for mum, dad and baby to
clean teeth twice a day
Action and follow up
Make a note on the 9 month form of any problems that need follow up
Issue or problem
Referral or action made
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
General comments
□ Prompt for 9 month check
□ Monthly recall for GAA
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
8
Signature
6 Month Examination
AHW
RN
Date
/
/
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Under 5s Program
www.nt.gov.au/health
January 2009
9 Month Assessment
Child Health Nurse, RAN or AHW to complete
Discussion points are in a black box. Tick as completed
Immunisation
Date Review
DOB
/
/
Age (Weeks)
/
/
Carer attending
Problems identified at previous check
Growth satisfactory?
Weight
Since this time yesterday has the baby had
Breast milk
Formula
Other milk
Tea
Is the child eating solids regularly?
Yes
What foods
Nutritional information and advice given?
Yes
R ear
L ear
Yes
Plot on growth chart
No
Water
No
Soft drink/cordial/fruit juice
No
Use NT Infant feeding guidelines
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
(these can damage teeth)
Skin
Spots seen? Yes
No
Other
Scabies
Sores
Ringworm
Treatment
No
No
“lift the lip” and check for colour changes in baby’s teeth
white, brown or black spots
No
Referred to dental therapist?
Referred to dentist?
Clear
Yes
Other (specify)
Treatment
Recurrent otitis media? (3 or more episodes in 6 months)
Yes
Persistent otitis media? (more than 3 months with perforation)
Yes
Hearing referral required?
Yes
No
(if yes record below)
Oral health
Action plan needed?
Child details
Surname
□ Given (record on immunisation sheet)
□ Up to date
□ Unable to give - placed on recall
Nutrition
HRN
Yes
Yes
Examination
First Name
General appearance and comments
No
No
PLAY GIve your child clean safe household things to handle, bang and drop
COMMUNICATE Respond to your child’s sounds and interests. Tell your child the names of things and people. Read books to your child
and talk about the pictures
NUTRITION Introduce lumpier food (Use the flipchart ‘A story about feeding babies’ nutrition advice from NT Infant Feeding Guidelines)
HYGIENE Keep face/hands clean to stop germs spreading from pus affected ears and runny noses. Use tissue spears to clean ears.
Bath baby regularly - at least every second day
ORAL HEALTH Start caring for baby’s new teeth when they first come through. Clean with a damp clean cloth (don’t use toothpaste until 18
Was DFV screen done at this visit?
Yes
No
Referral made
Yes
No
Use S&E Assessment form
Home
months). Check teeth and gums regularly for any colour changes. It is important for mum and dad and baby to clean teeth twice a day
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen today
with the mother or carer. Do not force people to participate in the screen if they do not want to.
If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Action and follow up
Make a note on the 12 month form of any problems that need follow up
Issue or problem
Referral or action made
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
□ Prompt for 12 month check
□ Monthly recall for GAA
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
Signature
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
AHW
RN
Date
/
9 Month Assessment
/
9
Under 5s Program
www.nt.gov.au/health
January 2009
12 Month Assessment
Child Health Nurse, RAN, AHW and MO to complete
First Name
HRN
Surname
Date Review
DOB
/
/
/
/
Carer attending
Age
Child details
Discussion points are in a black box. Tick as completed
Significant illnesses in last 6 months?
Any current concerns (ask about general health, crying, sleeping)
Any concerns about hearing?
Any concerns about vision?
Any concerns about general development?
Yes
Yes
Yes
General check
Problems Identified at previous check
No
No
No
Not sitting without support
No interest in people
Not understanding simple spoken words
Not pulling to stand
Not developed pincer grasp
Family concerns
Comments about development
Is the child attending playgroup/early childhood development activities on a regular basis?
Yes
Development
DEVELOPMENTAL POINTERS
One year olds should be mobile - crawling, bottom shuffling, starting to walk with support. They should be able to pick up small objects
(eg. eat solid food with fingers) and manipulate objects well. They should be starting to talk, saying single words with meaning and
understanding simple instructional words (eg food, drink, car)
If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
No
COMMUNICATE Ask your child simple questions. Respond to your child’s attempts to talk. Play games: Ask child to wave bye-bye.
Read books with your child and talk about the pictures
INJURY PREVENTION Now your child is becoming more mobile, watch closely around the campfire - keep safe from injuries and burns.
Watch closely around water - keep safe from drowning
HYGIENE Keep child’s face and hands clean to stop germs spreading from pus affected ears and runny noses. Use tissue spears to clean
ears and bath or shower at least every second day
PLAY Allow child to explore safely - always supervise
NUTRITION Start family foods - 3 meals and 2 snacks. Refer to NT infant feeding guidelines as shown in ‘A story about feeding babies’
Is the child eating solids regularly?
Yes
No
Breast milk
Formula
Other milk
Tea
Water
Soft drink/Cordial/Fruit juice
(these can damage teeth)
Other (specify)
Nutrition
Since this time yesterday has the baby had
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to.
If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Was DFV screen done at this visit?
Yes
No
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Referral made
Yes
No
Home
Other foods
Use S&E Assessment form
12 Month Assessment
10
Under 5s Program
www.nt.gov.au/health
January 2009
12 Month Examination
Action Plan needed?
Yes
Yes
No
No
Plot on growth chart
Hb
Rx (low Hb)
R ear
L ear
□ Already □ This visit (Record on immunisation sheet)
□ Unable to give - place on recall
Routine de-worm?
Oral health
“lift the lip” note colour and check
Gums
Healthy
Bleeding
Abscess
Teeth
Healthy
White spots
Caries
If caries present
1-3 teeth
Dental referral required?
Yes
No
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
Treatment
Not sure
Not sure
4 or more teeth
Dental referral urgent?
Tympanometry
Clear
CVS
Heart Sounds
Scabies
Sores
Ringworm
Normal
Other (specify)
Yes
Yes
No
No
Normal
Not normal
Not done
Recurrent otitis media? (3 episodes in 6 months)
Yes
No
Persistent otitis media? (more than 3 months with perforation)
Hearing referral required:
Skin
□ Yes
Examination
Length
12 month immunisation given?
Yes
No
Yes
No
(If yes record below)
Treatment
Abnormal
General appearance and comments
Chest
□ Persistent cough > 4 weeks
□ Recurrent prolonged wet cough
□ 2 episodes hospitalisation - resp. illness in last 12 months
□ 3 episodes hospitalisation - resp. illness since birth
If yes to any, refer for medical review and record
Medical Officer Examination
Weight gain satisfactory?
Weight
ORAL HEALTH Remember to clean teeth twice a day - Consider low fluoride toothpaste if water is not fluoridated
EAR HEALTH It’s good to start to teach the child how to blow their nose. Nose blowing helps to keep ears clear and helps stop
germs spreading to other babies in the family. Encourage carers to use tissue spears for pus affected ears. Throw tissues into a
bin and wash your hands after cleaning ears.
Action and follow up
Make a note on the 18 month form of any problems that need follow up
Issue or problem
Referral or action made
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
General appearance and comments
□ Prompt for 18 month check
□ Medicare claim 708 completed
□ Monthly recall for GAA
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
11
Signature
12 Month Examination
AHW
RN
DR Date
/
/
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/health
Under 5s Program
January 2009
18 Month Assessment
Child Health Nurse, RAN, AHW to complete
First Name
HRN
Surname
Date Review
DOB
/
/
/
Child details
Discussion points are in a black box. Tick as completed
/
Carer attending
Age
Any current concerns (ask about general health, crying, sleeping)
Any concerns about hearing?
Any concerns about language?
Any concerns about development?
Yes
Yes
Yes
General check
Problems Identified at previous check
Significant illnesses in last 6 months?
No
No
No
No constructive play
Not pointing at items
Poor eye contact
Not saying 6 words
Not walking alone
Not engaging in group activities
Comments about development
Development
DEVELOPMENTAL POINTERS
At 18 months children should be able to say at least six words in English or community language (eg. mum, dad, ball, milk, all gone). They can
point to familiar items on request (eg. body parts). They should be holding a cup and drinking from it and starting to feed themselves with a
spoon. They should be able to stop and pick up objects they have dropped. They should be walking (backwards and forwards) and climbing.
They tend to play for a couple of minutes and be curious about what is going on around them.
If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Family concerns
Is the child attending playgroup/early childhood development activities on a regular basis?
(Encourage attendance if available in community)
Yes
No
NA
COMMUNICATE To help your child learn to talk, it’s good to tell stories and sing. It’s good to use and encourage English as well as
community language. It’s good to talk to your child during daily tasks like cooking and sweeping
NUTRITION 3 meals per day plus 2 snacks. Refer to NT infant feeding guidelines as shown in ‘A story about feeding babies’
Yes
No
Since this time yesterday has the baby had
Breast milk
Formula
Other milk
Tea
Water
Soft drink/Cordial/Fruit juice
(these can damage teeth)
Other foods
Other (specify)
Nutrition
Is the child eating solids regularly?
HYGIENE The child is now old enough to start learning how to use the toilet and how to wash hands and face with soap and water
Adults
Does anyone smoke in the house/car? Yes
If yes consider brief intervention (SNAPE)
Children
No
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to.
If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Was DFV screen done at this visit?
Yes
No
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Referral made
Yes
No
Home
Number of people living in the house:
Use S&E Assessment form
18 Month Assessment
12
www.nt.gov.au/health
Under 5s Program
January 2009
18 Month Examination
Weight gain satisfactory?
Yes
Length
Hb
Action Plan needed?
No
Yes
L ear
□ Already □ This visit
No
□ Unable to give - place on recall
Rx (low Hb)
Routine de-worm?
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ Yes
(Record on immunisation sheet)
Plot on growth chart
Oral health
“lift the lip” note colour and check
Gums
Healthy
Bleeding
Abscess
Not sure
Teeth
Healthy
White spots
Caries
Not sure
If caries present
1-3 teeth
4 or more teeth
Dental referral required?
Yes
No
Dental referral urgent?
Yes
R ear
18 month immunisation given?
Yes
No
NA
Fluoride varnish applied?
□ Yes
Clear
/
/
□ Not able
□Already done
□ No
No
Skin
Next due
(Every 6 months)
Scabies
Sores
Ringworm
Examination
Weight
Other (specify)
Treatment
Treatment
Tympanometry
Normal
Not normal
Not done
Recurrent otitis media? (3 or more episodes in 6 months)
Yes
No
Persistent otitis media? (more than 3 months with perforation) Yes
No
Hearing referral required
Yes
No
(If yes record below)
General appearance and comments
Chest
□ Persistent cough > 4 weeks
□ Recurrent prolonged wet cough
□ 2 episodes hospitalisation - resp. illness in last 12 months
□ 3 episodes hospitalisation - resp. illness since birth
If yes to any, refer for medical review and record
ORAL HEALTH Child is now old enough for teeth to be cleaned with a small soft toothbrush and a pea size amount of child’s
low fluoride toothpaste. Lift the lip to check the teeth and gums for colour changes
EAR HEALTH It’s good to start to teach the child how to blow their nose. Nose blowing helps to keep ears clear and helps stop
germs spreading to other babies in the family
Action and follow up
Make a note on the 2 year form of any problems that need follow up
Issue or problem
Referral or action made
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
General comments
□ Prompt for 2 year check
□ Monthly recall for GAA
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
13
Signature
18 Month Examination
AHW
RN
Date
/
/
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/health
Under 5s Program
January 2009
2 Year Assessment
Child Health Nurse, RAN, AHW and MO to complete
HRN
Surname
Date Review
DOB
/
/
Age
/
Child details
Discussion points are in a black box. Tick as completed
First Name
/
Carer attending
Significant illnesses in last 6 months?
Any current concerns (ask about general health)
Any concerns about hearing?
Any concerns about vision?
Any concerns about general development?
Yes
Yes
Yes
No
No
No
DEVELOPMENTAL POINTERS
Two year olds should be able to say 50 to 100 words and use two words together (eg go car, mum drink). They should be able to answer
simple questions (say name when asked, “get your shoes”. They should be developing some fine motor skills (eg undressing themselves
with some help with buttons). They should be very mobile - walking, running, jumping, climbing. They should be able to kick and throw a
large ball. They should enjoy interactive games and playing with other children.
If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Not running
Not answering simple questions
Not interested in other children
Not talking well in language
Comments about development
Family concerns
Is the child attending playgroup/early childhood development activities on a regular basis?
(Strongly encourage attendance if available in community)
Yes
No
Development
General check
Problems Identified at previous check
NA
INJURY PREVENTION Need to watch children near roads and creeks, keep off the road and other dangers. Make sure children don’t climb
too high - falls from high places can cause injury
PLAY Vigorous outside play for as long as practicable, teaching to climb safely, run, hop, jump, kick, throw and catch balls
COMMUNICATE Encourage your child to talk and answer their questions. Teach your child stories, songs and games in English
as well as community language
Breast milk
Other foods
Formula
Other milk
Tea
Water
Soft drink/Cordial/Fruit juice
(these can damage teeth)
Nutrition
Since this time yesterday has the baby had
Other (specify)
ORAL HEALTH It’s good to drink water and limit sugary food and drinks to help keep teeth healthy. Brush your child’s teeth twice a day using
a small soft toothbrush and a pea size amount of child’s low fluoride toothpaste
HYGIENE Encourage your child to use the toilet. It’s good to encourage your child to wash their hands and face with soap. Encourage your
child to blow their nose. Nose blowing helps to keep ears clear and helps stop germs spreading to other babies and children in the family
NUTRITION 3 meals per day plus 2 snacks. Refer to NT infant feeding guidelines as shown in ‘A story about feeding babies’
Adults
Children
Does anyone smoke in the house/car? Yes
If yes consider brief intervention (SNAPE)
No
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to.
If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Was DFV screen done at this visit?
Yes
No
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Referral made
Yes
No
Home
Number of people living in the house:
Use S&E Assessment form
2 Year Assessment
14
www.nt.gov.au/health
Under 5s Program
January 2009
2 Year Examination
Height (standing)
Hb
Rx (low Hb)
Growth satisfactory?
Oral health “lift the lip” note colour and check
Gums
Healthy
Bleeding
Abscess
Not sure
Teeth
Healthy
White spots
Caries
Not sure
If caries present
1-3 teeth
4 or more teeth
Dental referral required?
Yes
No
Dental referral urgent?
Yes
L ear
No
Routine de-worm?
Yes
R ear
Yes
Plot on growth chart
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
No
Action plan?
Yes
No
Immunisation
□ Given (record on immunisation sheet)
□ Up to date
□ Unable to give - placed on recall
NA
Fluoride varnish applied?
□ Yes
No
Skin
Next due
(Every 6 months)
/
□ Not able
□Already done
□ No
Clear
/
Scabies
Sores
Examination
Weight
Ringworm
Other (specify)
Treatment
Treatment
Tympanometry
Normal
Not normal
Not done
Recurrent otitis media? (3 or more episodes in 6 months)
Yes
No
Persistent otitis media? (more than 3 months with perforation) Yes
No
Hearing referral required
Yes
No
(If yes record below)
Chest
□ Persistent cough > 4 weeks
□ Recurrent prolonged wet cough
□ 2 episodes hospitalisation - resp. illness in last 12 months
□ 3 episodes hospitalisation - resp. illness since birth
If yes to any, refer for medical review and record
CVS
Heart Sounds
Normal
Medical Officer
Examination
General comments
Abnormal
Action and follow up
Make a note on the 3 year old form of any problems that need follow up
Issue or problem
Referral or action made
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
General appearance and comments
□ Prompt for 3 year check
□ Medicare claim 708 completed
□ 6 Monthly GAA check due at 2½ years
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
15
Signature
2 Year Examination
AHW
RN
DR
Date
/
/
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
www.nt.gov.au/health
Under 5s Program
January 2009
3 Year Assessment
Child Health Nurse, RAN, AHW and MO to complete
Discussion points are in a black box. Tick as completed
First Name
Surname
DOB
/
/
Date Review
Age
/
Child details
HRN
/
Carer attending
Yes
Yes
Yes
No
No
No
DEVELOPMENTAL POINTERS
A three year old child should be starting to use 3-word sentences and following simple 2-step instructions (eg “get shirt from room”) and
should be starting to ask a lot of questions. They should be able to put on a T-shirt/shorts. A 3 year old should be able to throw and kick a
ball and should be starting to learn to walk up/down stairs without holding on. They should be able to copy a line and a circle and imitate
simple tasks such as cleaning if they have been exposed to these skills.
If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Not putting words together in phrases
Not engaging in active play with peers
Not understanding simple instructions
Unable to kick a ball
Comments about development
Family Concerns
Is the child attending playgroup/early childhood development activities on a regular basis?
(Strongly encourage attendance if available in community)
Yes
No
Development
Significant illnesses in last 6 months?
Any current concerns (ask about general health)
Any concerns about hearing?
Any concerns about vision?
Any concerns about general development?
General check
Problems Identified at previous check
NA
INJURY PREVENTION Car seats and seat belts protect kids in the car. Need to watch kids don’t climb too high - falls from high places can
cause injuries. Keep poisons and medicines up high and in their packets helps keep kids safe
PLAY Vigorous outside play for as long as practicable teaching to climb safely, run, hop, jump, kick, throw and catch balls
COMMUNICATE Encourage your child to talk and answer their questions. Teach your child stories, songs and games in English
as well as community language
Milk
Water
Tea
Other foods (list)
Soft drink/Cordial/Fruit juice
Nutrition
Since this time yesterday has the baby had
Other
(these can damage teeth)
NUTRITION 3 meals per day plus 2 snacks.
ORAL HEALTH Help your child to brush their teeth twice a day using a small soft toothbrush and a pea size amount of child’s fluoride
toothpaste. Decayed teeth are painful and need immediate treatment from a dentist or dental therapist
HYGIENE Encourage your child to use the toilet. It’s good to encourage your child to wash their hands and face with soap after using the
toilet and before meals. Encourage your child to blow their nose. Nose blowing helps to keep ears clear and helps stop germs spreading to
other babies and children in the family
Adults
Children
Does anyone smoke in the house/car? Yes
If yes consider brief intervention (SNAPE)
No
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to.
If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Was DFV screen done at this visit?
Yes
No
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Referral made
Yes
No
Home
Number of people living in the house:
Use S&E Assessment form
3 Year Assessment
16
Under 5s Program
www.nt.gov.au/health
January 2009
3 Year Examination
Height (standing)
Hb
Rx (low Hb)
Growth satisfactory?
Yes
No
Routine de-worm?
No
NA
Plot on growth chart
Oral health “lift the lip” note colour and check
Gums
Healthy
Bleeding
Abscess
Not sure
Teeth
Healthy
White spots
Caries
Not sure
If caries present
1-3 teeth
4 or more teeth
Dental referral required?
Yes
No
Dental referral urgent?
Yes
R ear
L ear
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
Yes
Immunisation
Given (record on immunisation sheet)
Up to date
Unable to give - placed on recall
□
□
□
Fluoride varnish applied?
□ Yes
Clear
/
/
□ Not able
□Already done
□ No
No
Skin
Next due
(Every 6 months)
Scabies
Sores
Examination
Weight
Ringworm
Other (specify)
Treatment
Treatment
Normal
Not normal
Not done
Recurrent otitis media? (3 or more episodes in 6 months)
Yes
No
Persistent otitis media? (more than 3 months with perforation)
Yes
No
Hearing referral required
Yes
No
(If yes record below)
General appearance and comments
Chest
□ Persistent cough > 4 weeks
□ Recurrent prolonged wet cough
□ 2 episodes hospitalisation - resp. illness in last 12 months
□ 3 episodes hospitalisation - resp. illness since birth
If yes to any, refer for medical review and record
CVS
Heart Sounds
Normal
Medical Officer
Examination
Tympanometry
Abnormal
Action and follow up
Make a note on the 4 year old form of any problems that need follow up
Issue or problem
Referral or action made
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
General comments
□ Prompt for 4 year check
□ Medicare claim 708 completed
□ 6 Monthly GAA check due at 3½ years
□ Weekly recall if concerns and engage community supports (eg SWSBSC, community liaison, family workers)
Name of person
completing check
17
Signature
3 Year Examination
AHW
RN
DR Date
/
/
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Under 5s Program
www.nt.gov.au/health
January 2009
4 Year Assessment
Child Health Nurse, RAN, AHW and MO to complete
First Name
HRN
Surname
Date Review
DOB
/
/
Age
/
/
Carer attending
Child details
Discussion points are in a black box. Tick as completed
Significant illnesses in last 6 months?
Any current concerns (ask about general health)
Any concerns about hearing?
Any concerns about language?
Any concerns about general development?
Yes
Yes
Yes
No
No
No
General check
Problems Identified in medical history
Milk
Tea
Water
Other foods (list)
Soft drink/Cordial/Fruit juice
Nutrition
Since this time yesterday has your child had
Other (specify)
(these can damage teeth)
DEVELOPMENTAL POINTERS
A 4 year old child should be able to listen to and understand simple stories. They should be able to tell stories and ask questions speaking
clearly (in language) and be able to be understood. They should be able to dress themselves, walk along a log, play ball games, enjoy playing
with other children and understand taking turns games.
Not using the toilet
Unable to convey messages
Unable to dress self
Family concerns
Development
If any of the following are observed OR the family is concerned TICK the box and refer to the doctor for review
Comments about development
Has the child started pre-school?
Yes
(Strongly encourage attendance if available in community)
No
NA
SOCIAL Help prepare children for school by being involved with the school and letting children know that parents/carers think school is
important. Parents reading to children regularly helps children to learn to read
PLAY Vigorous outside play - restrict TV/electronic games to less than 2 hours per day
BOOKLET Hand out and discuss the booklet: “Get Set 4 Life- Habits for Healthy Kids”
NUTRITION 3 meals per day plus 2 snacks. See the booklet: “Get Set 4 Life- Habits for Healthy Kids” (pages 12-15)
Domestic and family violence (DFV) assessment. Has a DFV screen been done in the last 6-12 months? If not offer to do a screen
today with the mother or carer. Do not force people to participate in the screen if they do not want to.
If the mother/carer agrees to the screen, ensure privacy and reassure them that all people are asked the same questions.
Offer to follow up and support mother/carer with any problems identified.
Was DFV screen done at this visit?
Yes
No
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S
Referral made
Yes
No
Home
General comments
Use S&E Assessment form
4 Year Assessment
18
Under 5s Program
www.nt.gov.au/health
January 2009
4 Year Examination
BMI
Growth satisfactory?
Is BMI in normal range?
Yes
L ear
□ Yes
□ No
Next due
L ear
Yes
No
No
Yes
No
Routine de-worm?
Yes
No
NA
1000Hz P F
F = Fail
Clear
4000Hz
P F
(please tick)
Scabies
Sores
Ringworm
Other (specify)
Persistent otitis media? (more than 3 months with perforation) Yes
Hearing referral required
/
25dB
P = Pass
Not done
Recurrent otitis media? (3 or more episodes in 6 months)
No
Hearing Screening - Only if no ear disease present
R ear
25dB
1000Hz P F
4000Hz P F
Skin
Not normal
Yes
□ Yes
□ Already □ This visit
(Record on immunisation sheet)
□ Unable to give - place on recall
□ Up to date
□ Not able
□Already done
Treatment
Normal
/
(Every 6 months)
Action plan?
4 year immunisation given?
Fluoride varnish applied?
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
□ NAD □ AOM □ AOM w Perf. □ CSOM □ OME
□ Dry Perf. □ Otitis Ext. □ Other (specify)
Tympanometry
No
Hb
No
Oral health
“lift the lip” note colour and check
Gums
Healthy
Bleeding
Abscess
Not sure
Teeth
Healthy
White spots
Caries
Not sure
If caries present
1-3 teeth
4 or more teeth
Dental referral required?
Yes
No
Dental referral urgent?
Yes
No
R ear
Yes
Plot on growth chart
Treatment
(If yes record below)
Visual acuity (Lea chart)
Trachoma
R eye
R eye
NAD
TF
TI
TS
L eye
L eye
NAD
TF
TI
TS
General appearance and comments
Chest
□ Persistent cough > 4 weeks
□ Recurrent prolonged wet cough
□ 2 episodes hospitalisation - resp. illness in last 12 months
□ 3 episodes hospitalisation - resp. illness since birth
If yes to any, refer for medical review and record
CVS
Heart Sounds
Normal
Examination
Height
(standing)
Abnormal
Medical Officer
Examination
Weight
Action and follow up
Issue or problem
□
Medicare claim 708 completed
Name of person
completing check
19
Referral or action made
□
Medicare claim 709 completed
Signature
4 Year Examination
Referred to
MO
Paed
Other (specify)
MO
Paed
Other (specify)
MO
Paed
Other (specify)
□
Medicare claim 711 (RAN/AHW) completed
AHW
RN
DR
Date
/
/
D E PA R T M E N T O F H E A LT H A N D FA M I L I E S