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Get NJ CH-14 2017-2024

A generic care plan CH-15 can be downloaded at www. nj. gov/health/forms/ch-15. dot or pdf. Hard copies of the CH-15 can be requested from the Division of Family Health Services at 609-292-5666. b. Medications - List any ongoing medications. Include any medications given at home if they might impact the child s health while in child care seizure cardiac or asthma medications etc.. Short-term medications such as antibiotics do not need to be listed on this form. Long-term antibiotics such as antibiotics for urinary tract infections or sickle cell prophylaxis should be included. PRN Medications are medications given only as needed and should have guidelines as to specific factors that should trigger medication administration. CH-14 Instructions Screening - This section is required for school WIC Head Start child care settings and some other programs. Endorsed by UNIVERSAL CHILD HEALTH RECORD American Academy of Pediatrics New Jersey Chapter New Jersey Academy of Family Physicians New Jersey Department of Health SECTION I - TO BE COMPLETED BY PARENT S Child s Name Last First Date of Birth Gender Male Does Child Have Health Insurance Yes / Female If Yes Name of Child s Health Insurance Carrier No Parent/Guardian Name Home Telephone Number Work Telephone/Cell Phone Number I give my consent for my child s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form* Signature/Date This form may be released to WIC. Date of Physical Examination Results of physical examination normal Abnormalities Noted Weight must be taken within 30 days for WIC Head Circumference if 2 Years Blood Pressure Immunization Record Attached Date Next Immunization Due IMMUNIZATIONS MEDICAL CONDITIONS Chronic Medical Conditions/Related Surgeries List medical conditions/ongoing surgical concerns None Special Care Plan Attached Medications/Treatments List medications/treatments Limitations to Physical Activity List limitations/special considerations Special Equipment Needs List items necessary for daily activities Allergies/Sensitivities List allergies Special Diet/Vitamin Mineral Supplements List dietary specifications Behavioral Issues/Mental Health Diagnosis List behavioral/mental health issues/concerns Emergency Plans List emergency plan that might be needed and the sign/symptoms to watch for Comments PREVENTIVE HEALTH SCREENINGS Type Screening Date Performed Record Value Hgb/Hct Lead Note if Abnormal Hearing Capillary Venous Vision TB mm of Induration Dental Other Developmental Scoliosis I have examined the above student and reviewed his/her health history. It is my opinion that he/she is medically cleared to participate fully in all child care/school activities including physical education and competitive contact sports unless noted above. Health Care Provider Stamp Name of Health Care Provider Print CH-14 JUL 12 Distribution Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider Instructions for Completing the Universal Child Health Record CH-14 Section 1 - Parent Please be specific about what over-the-counter OTC medications you recommend and include information for the parent and child care provider as to dosage route frequency and possible side effects. .

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