Form 1 Medical Complaint Form

OMB Control No: 0970-XXXX

Expiration date: XX/XX/XXXX

Medical Complaint Form Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)

General Information (to be completed by program staff)

Child

Last name:

First name:

DOB:

A#:

Gender:

Healthcare Provider

Name: MD / DO / PA / NP

Phone number:

Clinic or Practice:

Street address:

City or Town:

State:

Date evaluated:

Location where child received care (e.g., onsite, offsite, ER, Admitted to hospital):

Program

Name of program staff with child:

Program name:

Reason for medical visit (e.g., asthma, immunizations, fever, injury):

History and Physical Exam (to be completed by healthcare provider)

Vital Signs

T (Co):

BP (> 3 years):

HR:

RR:

Ht (cm):

Wt (kg):

History of present illness / condition:

Allergies to medications:

No

Yes, specify: _____________________________________________________

Review of Systems (ROS): Check all applicable signs and symptoms and enter the date each began.

No abnormal findings

Pain, location: ____________________

___/____/____

Fever (>37.8 Co) or chills

___/____/____

Red eyes

___/____/____

Runny nose

___/____/____

Sore throat

___/____/____

Cough

___/____/____

Difficulty breathing/Shortness of breath/Wheezing

___/____/____

Nausea

___/____/____

Vomiting

___/____/____

Diarrhea

___/____/____

Neck stiffness

___/____/____

Headache

___/____/____

Confusion/Altered mental status

___/____/____

Dizziness

___/____/____

Neurologic symptoms

___/____/____

Skin lesions or rash

___/____/____

Yellow skin or eyes

___/____/____

Swollen glands

___/____/____

Unusual bleeding

___/____/____

Other 1, specify: ___________________________________________________________________________ ___/____/____ Other 2, specify: ___________________________________________________________________________ ___/____/____ Other 3, specify: ___________________________________________________________________________ ___/____/____

Exam Findings:

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Assessment / Diagnosis and Plan

Assessment/ Diagnosis:

Child without new complaints, symptoms, diagnoses/conditions; no prescription meds or referrals needed:

• No

• Yes

If No, check all diagnoses that apply. If “Other” is selected, specify in the space provided.

General / Constitutional

Allergy (e.g., drug reaction, food allergy), specify: ________________________________
Dehydration	Malnourished
Other 1: ________________________________ Other 2: ________________________________

HEENT

Headache/Migraine	Hearing issues
Otitis media/Ear infection	Pharyngitis (Not strep throat)
Rhinitis	Strep throat
Vision issues	Viral/Bacterial Conjunctivitis
Other 1: ________________________________
Other 2: ________________________________

Respiratory / Pulmonary

Asthma	Influenza-like illness (ILI)
Influenza, lab-confirmed; specify: ______________
Upper/lower respiratory illness; specify: _______________________________________
Other 1: ________________________________ Other 2: ________________________________

Cardiovascular

Heart murmur	Syncope/fainting
Other 1: ________________________________ Other 2: ________________________________

Gastrointestinal

Abdominal pain	Gastroenteritis
Heartburn/reflux	Intestinal parasites
Other 1: ________________________________ Other 2: ________________________________

Genito-urinary / Reproductive

Childbirth	Elective abortion
Genital warts	Pregnancy/Pregnancy-related
Spontaneous abortion	Urinary tract infection
Other 1: ________________________________ Other 2: ________________________________

Neurological

Developmental delay	Seizure/epilepsy
Other 1: ________________________________ Other 2: ________________________________

Skin, Hair, and Nails

Cellulitis	Dermatitis/Rash (not acne)
Ingrown toenail	Lice
Scabies	Tinea pedis
Other 1: ________________________________ Other 2: ________________________________

Musculoskeletal

Back pain	Fracture
Leg pain	Sprain/Strain
Other 1: ________________________________ Other 2: ________________________________

Potentially Reportable Infectious Disease

Acute hepatitis A	Acute/chronic hepatitis B
Acute/chronic hepatitis C	Chikungunya
Chlamydia	Dengue
Gonorrhea	HIV
Malaria	Measles
Mumps	Pertussis
Rubella	Sepsis/Meningitis
Syphilis	TB
Typhoid fever	Varicella
Viral hemorrhagic fever, specify: ______________	Zika virus
Other 1: _______________________________ Other 2: _______________________________

Abuse

Sexual	Physical
Other 1: ________________________________ Other 2: ________________________________

• Other, Medical: _______________________________________

________________________________________

Plan: Specify in the space provided (e.g., labs ordered, referrals, medications, immunizations)

Child quarantined/isolated at the program for a diagnosis:

• No

• Yes, specify: __________________________________

Release of child from the program delayed because of a diagnosis:

• No

• Yes, specify: __________________________________

Recommendations from healthcare provider:

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Potentially Reportable Infectious Diseases
Lab testing performed to confirm the diagnosis:	No	Yes
Health department notified by program:	No	Yes	Not applicable
Intakes delayed/postponed because of this diagnosis:	No	Yes
UC exposed to this child while infectious:	No	Yes (enter a Contact Investigation Form for each exposed UC)
Number of staff members exposed to this diagnosis:

Potentially Reportable Infectious Disease (Non-TB) Lab Testing
Disease Tested	Collection Date	Specimen Type (e.g., Serum)	Test Type (e.g., IgM)	Result

Bacteriologic Results (TB)
Collection Date	Specimen Type (e.g., Sputum)		Test Type (e.g., AFB smear)			Result
Special Requirements for Release
If the child had been AFB smear positive, list the dates of the 3 consecutive negative AFB smears:		#1:		#2:	#3:
If the TB culture was positive and the DST was MDR or XDR, list the dates of the 2 subsequent negative cultures:		#1:		#2:

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THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

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