CP&P 11-3
(rev. 10/2007)
State of New Jersey
DEPARTMENT OF CHILDREN AND FAMILIES
Pre-Placement/Re-Placement Assessment
Case ID #
Pre-placement
Date of Assessment
CHILD
M
F
First
Last
Date of Birth
INSURANCE
Medicaid Number
HMO
CP&P WORKER
First
Last
SPRU WORKER
First
Last
HEALTH
PROFESSIONAL
First
Last
Contact Number
Other Insurance
CP&P Local Office
County SPRU Operation
Title / Position
Location
CURRENT
COMPLAINTS
PAST MEDICAL
HISTORY
PAST SURGICAL
HISTORY
IMMUNIZATION
HISTORY
None
Non-verbal child
As follows
Unknown
None
As follows
Unknown
None
As follows
See attached
records
Not available at time of
assessment
MEDICATIONS
Unknown
None
As follows
ALLERGIES
No known drug
allergies
No known food allergies
Other allergies
Additional information (Maximum 200 characters)
Does child complain of pain? Yes
No
Non-verbal
Describe pain (Maximum 50 characters)
Wong Faces Score
or Linear Graph Score
Page 1 of 4
Re-placement
CP&P 11-3
(rev. 10/2007)
Review of Systems
General
none
chills
fatigue
fever
none
dizziness
headache
head
injury
none
blurred vision
glasses/lenses
strabismus
none
decreased hearing
discharge
pain
none
congestion
rhinorrhea
none
hoarse
sore
none
cough
shortness of breath
wheeze
none
chest pain
rapid heart rate
syncope
none
constipation
diarrhea
emesis
encopresis
none
discharge
dysuria
enuresis
trauma
none
swelling
trauma
none
tingling
weakness
none
jaundice
pruritis
Head
Eyes
Ears
Nose
Throat
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Skin
rash
Additional information (Maximum 250 characters)
Physical Assessment
Temp
Method
HR
HT (cm) / Percentage
RR
BP
BMI / Percentage
WT (kg) / Percentage
HC (cm) / Percentage
General
Other
wellappearing
lethargic
inconsolable
normal
bruising
hair loss
lice / nits
scaling
normal
discharge
erythema
injection
icterus
normal
discharge
foreign body
inflamed TM
normal
foreign body
rhinorrhea
normal
cavities
ulcers
normal
crackles
white patches
decreased breath
sounds
stridor
wheeze
normal
murmur
normal
guarding
mass
rebound
tender
normal
child refused
external injury
rash
testicular mass
normal
deformity
swollen joint
tender
normal
abnormal gait
weakness
normal
rash
focal deficit
bruising/marks
injury (see body
diagrams)
Head
Eyes
Ears
Nose
Throat
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Extremities
Neurological
Skin
Additional information (Maximum 250 characters)
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CP&P 11-3
(rev. 10/2007)
None noted
Description of Injuries (Maximum 500 characters)
Assessment
To the best of my knowledge, based upon the above history and physical and all
information available at this time, this child is
1. Free from communicable illness
Yes
No
2. Free from acute injury requiring immediate medical attention
Yes
No
3. Free from acute medical illness requiring immediate medical
attention
4. In need of special transportation (If so specify needs below in
plan/follow-up below
Yes
No
Yes
No
Assessment Summary (Maximum 500 characters)
Page 3 of 4
CP&P 11-3
(rev. 10/2007)
Plan / Recommendation for Follow-Up (Maximum 1500 characters)
Name, Title, and Date (please print and sign)
Provider Stamp
_______________________________________
Signature
_______________________________________
Date
Time
DISTRIBUTION:
ORIGINAL
COPY
COPY
EMAIL
EMAIL
WORKER
HEALTH CARE PROFESSIONAL
CAREGIVER
WORKER
LO NURSE
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