Child & Adolescent Health Examination Form for NYC
This form is used by parents or guardians to provide detailed health and medical history information for children and adolescents. It includes sections to be completed by both the parent/guardian and the health care practitioner. The form is essential for school enrollment and other child care services in NYC.
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How do I fill this out?
To fill out this form, start by entering the child's personal information and medical history. The parent or guardian should complete all relevant sections before the health care practitioner fills out the medical examination sections. Ensure all information is accurate and up-to-date before submission.
How to fill out the Child & Adolescent Health Examination Form for NYC?
1
Enter the child's personal information.
2
Complete the medical history section as the parent or guardian.
3
Have the health care practitioner fill out the physical exam section.
4
Review the completed form for accuracy.
5
Submit the form to the relevant authority.
Who needs the Child & Adolescent Health Examination Form for NYC?
1
Parents of children enrolling in NYC schools need this form for school registration.
2
Guardians of children attending child care centers or camps need this form for enrollment.
3
Foster parents need this form to provide updated medical information to relevant agencies.
4
Health care practitioners need this form to document the medical examination of the child.
5
Schools and child care centers require this form to ensure the child's health and immunization status.
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1
Open the PDF on PrintFriendly's editor.
2
Enter the child's personal details in the designated fields.
3
Fill out the medical history section as the parent or guardian.
4
Schedule an appointment with the health care practitioner to complete the examination section.
5
Review the form for accuracy and completeness before saving and downloading.
What are the instructions for submitting this form?
To submit this form, ensure all sections are complete and accurate. Submit the form to your child's school or the relevant child care center. For schools, submit via email or through the school's online submission portal. For child care centers, submit directly to the administration office. Always keep a copy for your records. Ensure deadlines are met to avoid delays in services.
What are the important dates for this form in 2024 and 2025?
Make sure the form is completed before the 2024/2025 school year begins. Check with your school or child care center for specific submission deadlines.
What is the purpose of this form?
The purpose of this form is to provide a comprehensive health record for children and adolescents in NYC. It includes sections to capture personal information, medical history, and physical examination details. The completed form is essential for school enrollment, child care, and other related services.
Tell me about this form and its components and fields line-by-line.
- 1. Child's Last Name: Enter the child's last name.
- 2. First Name: Enter the child's first name.
- 3. Date of Birth: Enter the child's date of birth in MM/DD/YYYY format.
- 4. Sex: Select the child's sex.
- 5. Race: Check all race categories that apply.
- 6. Health Insurance: Indicate if the child has health insurance, including Medicaid.
- 7. Parent/Guardian Name: Enter the last and first name of the parent or guardian.
- 8. Birth History: Indicate if the child's birth history was uncomplicated or complicated.
- 9. Allergies: List any allergies the child has and specify if an EpiPen is prescribed.
- 10. Asthma: Indicate if the child has asthma and provide details on medications and control status if persistent.
- 11. Seizure Disorder: Indicate if the child has a seizure disorder.
- 12. Physical Exam: Enter the date of the exam and the examining health care practitioner's details.
What happens if I fail to submit this form?
Failure to submit this form can result in delays or denial of school enrollment or child care services. It is crucial to ensure the form is accurately completed and submitted on time.
- School Enrollment Delays: Your child may not be able to start school on time.
- Denial of Child Care Services: Without the form, child care centers may refuse to provide services.
- Incomplete Health Records: Not submitting the form results in incomplete health records for the child.
How do I know when to use this form?
- 1. School Enrollment: Required for enrolling a child in school.
- 2. Child Care Services: Needed for child care centers and camps.
- 3. Medical History Documentation: Provides a comprehensive record of the child's medical history.
- 4. Health Monitoring: Used to monitor the child's health and developmental progress.
- 5. Emergency Preparedness: Ensures that schools and care centers can provide appropriate care during emergencies.
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What sections does this form include?
The form includes personal details, medical history, and a physical examination section.
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