CASE I.D.
Georgia Department of Human Resources
CHILD’S NAME
PHYSICAL APPRAISAL
NO. _______________
MARK X FOR UNSATISFACTORY
ITEMS AND MAKE COMMENTS
Age:
HT:
WT:
BMI:
Years
Mos.
Ins.
Lbs.
%
Head Cir:
in.
(< 2 yr)
Lymph Nodes
Eyes -Pupillary Action
Vision Test
Eyegrounds
Other
Ears -Otoscopic
Hearing
Other
Nasal Passages
Throat -Pharynx
Tonsils
Adenoids
DATE
3/8/2016
CHRONOLOGICAL NOTES (Provider)
Objective:
Gen: Child playful, cooperative, appears
generally healthy, in no acute distress. HEENT: WNL no
signs of trauma, Neck: Supple, no stiffness, no pain,
tenderness or swelling observed, Chest/CV: No signs of chest
trauma, normal S1S2, no palpitations, regular rate and
rhythm, no cough, no murmurs, rubs or gallops.
Lungs: breath sounds clear bilaterally, no adventitious breath
sounds, no rales, crackles or wheezes or rhonchi auscultated.
BP:
Pulse Ox:
T:
P:
Abdomen: soft, nontender, no masses bowel sounds present
R:
in all quadrants. GU: normal external genitalia, no notable
discharge, lesions or abnormal genitalia. Tanner Stage Rectal: no lesions, notable
hemorrhoids, gross blood in stool. No signs of rectal trauma.
Extremities: full range of motion, no deformities, edema, erythema or limitations. Child able
to hop, skip, balance on one foot, duck walk, and squat. Neuro: No local finding, alert and
oriented x 3. Skin: no rashes, lesion, ecchymosis, skin break down or signs of trauma.
Surveillance: Normal appearing emotional, communication, cognitive, and physical
development
Assessment:
Normal well child exam
Plan:
Encouraged to follow up with pediatrician in 1-2 weeks. Follow up with dentist in 1-2
weeks for screening and cleaning. Encouraged child safety, back seat passenger riding,
seat belts, and to wear appropriate safety equipment when playing. Encouraged brushing teeth
2 times daily and begin flossing. Review GRITS immunization records and gave copy.
 CBC  BMP CMP  TSH U/A PT/PTT  Lead Level (12,24 m) or (36,72m if absent)
 Immunizations H&H (12m) TB skin test Other_____________________
 Lead risk assessment(6,9,12m)  TB risk assessment(1,6,12,18m)  Nutrition/Growth
assessment (growth chart) Alcohol and Drug use assessment Anemia Assessment (4,18,24 m
then annual)  Dyslipidemia assessment (2,4,6,8,10y)
Gums
Tongue
Palate
Chest --
X
BIRTHDATE
(11)
Heart
Lungs
Abdomen
Skeletal System
Neuromuscular System
Psychological Problems
Audiometry referral(4,6,8,10y)
Other Tests
IMPRESSION AND INSTRUCTIONS: See plan above
HEALTH EXAMINER SIGNATURE
stamp