1 Initial Medical Exam Form

Initial Medical Exam Form and Dental Exam Form

Initial Medical Exam Form_0466_Updated 05062022

OMB: 0970-0466

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OMB Control No: 0970-0466

Expiration date: 12/31/2023


Initial Medical Exam Form

Unaccompanied Children’s Program

Office of Refugee Resettlement (ORR)

General Information

Minor

Last name:

First name:

DOB:

A#:

Gender:

Healthcare Provider (HCP)

Name:

MD / DO / PA / NP

Phone number:

Clinic or Practice:

Street address:

City or Town:

State:

Date evaluated:

Program

Program name:

  • Program Staff Member Present During Exam with HCP

History and Physical Assessment

Vital Signs

Temperature (T)

Heart Rate (HR)

BP (> 3 yrs)

Resp Rate (RR)

Height (HT)

Weight (WT)

BMI (>2 yrs)

BMI %ile

F / C





in / cm


lbs / kg



Allergies:

  • No

  • Yes, specify below


Food

Medication

Environmental

Other

Allergen





Reaction





Vision Screening (> 3 years):

  • No

  • Yes, specify below

Hearing Screening:

  • No

  • Yes, specify below


Right Eye

Left Eye

Both eyes

Final

OAE/ABR

  • Pass

  • Fail

Corrected

20 /

20 /

20 /

  • Pass

  • Fail

Gross Hearing (< 4 Years)

  • Pass

  • Fail

Uncorrected

20 /

20 /

20 /

  • Pass

  • Fail

Pure Tone Audiometry (>= 4 Years) Result

  • Pass

  • Fail

Medical History

Concerns expressed by child or caregiver:

  • No

  • Yes, specify:


Past medical history (include surgeries and hospital admissions):

Was healthcare received in DHS custody?

  • No

  • Yes, specify:


Social/Family History:

Travel history (countries visited, dates of arrival and departure for each):

Reproductive History:

  • Menarche: Date of LMP: ____ / ____ / _____, if unknown, months since LMP: ______;

  • Pregnancy: Gravida ______ Parity ______

  • N/A

Review of Systems (ROS) and Physical Exam

Were any signs/symptoms reported by the minor or observed by program staff or HCP?

  • No

  • Yes, check all applicable signs/symptoms and enter the onset date (mm/dd/yyyy):

Sign/Symptom

  • Pain, location:

_____________

  • Fever (>37.8 Co) or chills

  • Red Eyes

  • Runny Nose

  • Sore Throat

  • Cough

  • Difficulty breathing/ Shortness of Breath

Onset Date








Sign/Symptom

  • Nausea

  • Vomiting

  • Diarrhea

  • Neck stiffness

  • Headache

  • Dizziness

  • Confusion/Altered mental status

Onset Date








Sign/Symptom

  • Neurologic symptoms

  • Skin lesions/Rash

  • Yellow skin/eyes

  • Swollen glands

  • Unusual bleeding

  • Other: ___________

  • Other: _____________

Onset Date










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Physical Examination

System

Not eval

Evaluated, Findings

Describe or if not evaluated, provide reason

General appearance

  • Normal

  • Abnormal


HEENT

  • Normal

  • Abnormal


Neck

  • Normal

  • Abnormal


Heart

  • Normal

  • Abnormal


Lungs

  • Normal

  • Abnormal


GU/GYN

  • Normal

  • Abnormal


Extremities

  • Normal

  • Abnormal


Abdomen

  • Normal

  • Abnormal


Back/Spine

  • Normal

  • Abnormal


Neurologic

  • Normal

  • Abnormal


Skin (include tattoos)

  • Normal

  • Abnormal


Other: _________________

  • Normal

  • Abnormal


Psychosocial Risk

Mental Health Concerns (< 3 mos)

  • Yes, specify below

  • Denied, with no obvious signs/symptoms

  • Denied, but obvious signs/symptoms present

  • Unable to obtain/report response, specify reason ________________________________________

  • Feels empty, hopeless, sad, numb more often than not

  • Has trouble concentrating, restless, too many thoughts

  • Feels constantly worried, anxious, nervous more often than not

  • Has trouble eating, sleeping

  • Experiences mood swings, from very high to very low

  • Feels helpless

  • Relives traumatic events from the past

  • Feels like hurting others

  • Feels easily annoyed or irritated

  • Feels like hurting self, would be better off dead

  • Feels afraid, easily startled, jumpy

  • Other concerns: ______________________________________________

Is minor able to attribute these feelings to a specific reason(s)?

  • No

  • Yes, specify:_____________________________________________________

Physical Abuse History

  • Yes, specify below

  • Denied, with no obvious signs/symptoms

  • Denied, but obvious signs/symptoms present

  • Unable to obtain/report response, specify reason ________________________________________

Specify who/when/where: __________________________________________________________ ________________________________________________________________________________

  • Part/All of abuse related to gang violence

  • In home country

  • During journey to U.S.

  • In U.S., not in ORR custody

  • In ORR custody

Sexual Activity History

  • Yes, specify below

  • Denied, with no obvious signs/symptoms

  • Denied, but obvious signs/symptoms present

  • Unable to obtain/report response, specify reason ________________________________________

Sexual activity (Oral/Vaginal/Anal)

Date of Last Encounter

Location

In home country

During journey to U.S.

In U.S., not in ORR custody

In ORR custody

  • Consensual

___/___/____

Specify:

  • Nonconsensual

___/___/____

Specify:

Substance Use History

  • Yes, specify below

  • Denied, with no obvious signs/symptoms

  • Denied, but obvious signs/symptoms present

  • Unable to obtain/report response, specify reason _______________________________________


Alcohol

Tobacco / Nicotine

Marijuana

Injection drugs

Other substances

Specify substance(s)



N/A



Frequency of use






Date of last use






Laboratory Testing

Condition

Indicators

Test

Result

Influenza

Fever + cough or sore throat

  • Rapid flu

  • Negative

  • Positive, type:

  • A

  • B

  • A/B

  • Unk

Strep throat

Sore throat + fever without cough

  • Rapid strep

  • Negative

  • Positive

Lead

6 mos up to 6 yrs

  • Capillary, Lead

  • Ordered/Pending

  • Negative

  • Positive (>5 mcg/dl), level: ___

  • Blood/Serum, Lead

  • Ordered/Pending

Pregnancy

­>10 yrs or < 10 yrs who have reached menarche or sexual activity

  • Urine pregnancy

  • Negative

  • Positive

  • Indeterminate

  • Blood/Serum hCG

  • Ordered/Pending

HIV

>13 yrs or Sexual activity

  • Rapid oral

  • Negative

  • Positive

  • Indeterminate

  • Blood/Serum, 4th Gen

  • Ordered/Pending

Chlamydia

Sexual activity

  • NAAT/PCR

  • Ordered/Pending

Gonorrhea

Sexual activity

  • NAAT/PCR

  • Ordered/Pending

Syphilis

Sexual activity

  • RPR/VRDL

  • Ordered/Pending

Hepatitis B

Sexual activity or Injection drug use

  • Surface antigen

  • Ordered/Pending

Hepatitis C

Injection drug use

  • Total antibody

  • Ordered/Pending

Other Reportable Infectious Disease (Non-TB):


Specify:

  • Ordered/Pending
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TB Lab Testing (Use Supplemental TB Screening form for result documentation)

Has minor ever been a close contact to a person with active TB disease?

  • No

  • Yes, specify:

Has minor ever been treated for active TB disease?

  • No

  • Yes, specify:

Has minor ever been treated for latent TB infection?

  • No

  • Yes, specify:

TB screening method ordered:

  • TST (<2 yrs)

  • IGRA (>2 yrs)

  • CXR (>15 yrs)

  • Was or will be tested elsewhere

Diagnosis and Plan

Diagnosis:

Minor with complaints, symptoms, diagnoses/conditions; meds prescribed (including OTC) or referrals needed:

  • No

  • Yes

If Yes, check all diagnoses that apply. Specify in the space provided, where indicated.

General/Constitutional

  • Anemia

  • Allergy (e.g., drug reaction, food allergy): ________________________

  • Dehydration

  • Lead poisoning

  • Lymphadenopathy

  • Malnourished

  • Pallor

  • Other: _______________________________________________________________________________________________________________________

HEENT

  • Conjunctivitis

  • Eyelid lesions

  • Otitis media/externa

  • Rhinitis

  • Hearing issues: __________________________

  • Speech impediment

  • Strep throat

  • Pharyngitis (Not strep throat)

  • Vision issues: ____________________________

  • Other: ____________________________________________________________________________

Respiratory/Pulmonary

  • Asthma

  • Chronic cough

  • Abnormal CXR (Non-TB): __________________

  • Lower respiratory illness: __________________

  • Upper respiratory illness: _________________________

  • Influenza-like illness (ILI)

  • Influenza, lab-confirmed

  • Other: ____________________________________________________________________________

Cardiovascular

  • Arrhythmia

  • Elevated blood pressure

  • Chest pain

  • Heart murmur

  • Syncope/fainting

  • Congenital heart disease: _____________________________________________________________

  • Acquired heart disease: ___________________

  • Other: ____________________________________________________________________________

Endocrine Disorder

  • Diabetes, Type 1 and 2

  • Hyper/Hypothyroidism

  • Delayed/Precocious puberty

  • Other: ________________________________________________________________________________________________________________________

Gastrointestinal

  • Abdominal pain

  • Constipation

  • Celiac disease

  • Diarrhea, Acute/Chronic

  • Failure to thrive

  • Gastritis/Peptic ulcer

  • Gastroenteritis

  • GI bleeding

  • Heartburn/Reflux

  • Jaundice

  • Liver disease

  • Weight loss

  • Inflammatory bowel disease

  • Intestinal parasites: _________________________________

  • Other: ________________________________________________________________________________________________________________________

Genito-urinary/Reproductive

  • Bed-wetting

  • Hematuria

  • Proteinuria

  • Inguinal hernia

  • Kidney stones

  • Urinary tract infection

  • Testicular torsion

  • Hydrocele/Varicocele

  • Abnormal Vaginal Bleeding/Discharge

  • Amenorrhea/Dysmenorrhea /Menorrhagia

  • Gynecomastia/Breast Mass (fibroadenomas, cysts)

  • Consensual sexual activity

  • Pelvic Inflammatory Disease

  • Genital warts

  • Pregnant

  • Childbirth

  • Other: ________________________________________________________________________________________________________________________

Neurological

  • Brain tumor

  • Cerebral palsy

  • Cerebrovascular disease

  • Cognitive disorder/IQ deficit

  • Developmental delay

  • Headache/Migraine

  • Neurocysticercosis

  • Traumatic brain injury / Concussion

  • Seizure/Epilepsy

  • Other: ____________________________________________________

Musculoskeletal

  • Back pain

  • Extremity/Joint pain

  • Bone tumors (benign/malignant)

  • Fracture

  • Sprain/Strain

  • Scoliosis/Kyphosis

  • Ligamentous/Tendon injury

  • Other: _________________________

Skin, Hair, and Nails

  • Acne

  • Atopic dermatitis/Eczema

  • Allergic/Irritant Contact Dermatitis

  • Lice

  • Scabies

  • Ingrown toenail

  • Acanthosis Nigricans

  • Hair loss/Alopecia Areata

  • Cellulitis

  • Ringworm

  • Tattoos

  • Tinea pedis

  • Onychomycosis

  • Scars

  • Warts

  • Other: ____________________________________________________________________________

Potentially Reportable Infectious Disease

  • Acute hepatitis A

  • Acute/chronic hepatitis B

  • Acute/chronic hepatitis C

  • Chikungunya

  • Chlamydia

  • COVID-19

  • Dengue

  • Gonorrhea

  • HIV

  • Malaria

  • Measles

  • Mumps

  • Pertussis

  • Rubella

  • Sepsis/Meningitis

  • Syphilis

  • TB, active disease

  • TB, latent (LTBI)

  • Typhoid fever

  • Varicella

  • Zika virus

  • Viral hemorrhagic fever: ______________________________________

  • Other: ________________________________________________________________________________________________________________________

Medical, Other





Behavioral and Mental Health Concerns

  • Anxiety symptoms (e.g., panic attacks, excessive worry/fear)

  • Depressive symptoms

  • Manic symptoms (e.g., elated mood, pressured speech)

  • Trauma symptoms (e.g., nightmares, flashbacks)

  • Hallucinations

  • Delusions

  • Behavioral concerns (e.g., aggression, trouble following rules)

  • Social/Emotional delay

  • History of psychiatric diagnoses or treatment: _____________________________

  • Urge for/current self-harm

  • Urge for/current harm to others

  • Nonconsensual sexual activity

  • Other: ________________________________________________________________________________________

Dental

  • Broken tooth or teeth

  • Gingivitis/gum disease

  • Impacted tooth/teeth

  • Infection/abscess

  • Tooth decay/caries

  • Tooth sensitivity

  • Other: _______________________________________________
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Plan: Check all that apply and specify where indicated. Please provide copies of office notes, lab/imaging results, and immunization records to program staff.

Return to clinic:

  • PRN/As needed


  • Follow-up (specify diagnosis, timing): _________________________________________________________________________

Minor fit to travel

  • Yes

  • No: ____________________________________________________________________________________________

Per program staff, discharge from ORR custody will be delayed:

  • No

  • Yes (specify diagnosis, timing): __________________________________

Minor has/may have an ADA disability:

  • No

  • Yes: _______________________________________________________________________________

  • Referred to specialist/counselor: _________________________________________________________________________________________________

  • Minor requires quarantine/isolation, specify diagnosis and timeframe: ___________________________________________________________________

  • Medications (specify name, diagnosis treated, date started, dose, and directions and indicate if psychotropic):

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

  • Immunizations given/validated from foreign record

  • List immunizations that were indicated, but not given and state why: ____________________________________________________________________

____________________________________________________________________________________________________________________________

  • Age-appropriate anticipatory guidance discussed and/or handout given

  • Physical/dietary restrictions:_____________________________________________________________________________________________________

  • Visiting nurse services required: __________________________________________________________________________________________________

  • Physical/Occupational/Speech therapy required: ____________________________________________________________________________________

  • Durable medical equipment required: _____________________________________________________________________________________________

  • Per local/state reporting guidelines, Health Department was notified of suspect/confirmed diagnosis of a reportable infectious disease

Were other minors in ORR custody potentially exposed during infectious period?

  • No

  • Yes

Were grantee staff members potentially exposed at care provider program?

  • No

  • Yes

  • Other:



Recommendations from Healthcare Provider / Additional Information












Healthcare Provider Signature: ______________________________________________________________ Date: _______ / ______ / __________



Healthcare Provider Printed Name: ___________________________________________________________
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PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 13 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0466 and the expiration date is 12/31/2023. If you have any comments on this collection of information, please contact UACPolicy@acf.hhs.gov.



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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBuckley, Kirsten (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2022-05-23
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