Physical Exam Checklist

Transcription

1 1021 West 14 th Street P. O. Box 968 Hastings, Nebraska Appointments (402) Business (402) Fax (402) Physical Exam Checklist This information is being sent to you for an upcoming school related exam. Please review the following section that applies to the person having the physical. If you have any questions about this information, please call us at (402) th Grade Physical Forms Please complete the top section of the Department of Health & Human Services Physical Examination Report prior to your examination. It is required that this form be completed and signed by Parent (or Guardian) and the child before the child is seen by the Provider. Additionally, complete the first page of the Preparticipation Physical Evaluation form. Immunizations Please bring a complete record of immunizations with you, even if child has received all of their vaccines in the clinic. Urine specimens are needed for all physicals. For some children this can be overwhelming, and it is acceptable to bring a specimen from home for children of all ages. Be sure to put the child s name on the container. If it will be more than an hour before the appointment please refrigerate the urine to prevent chemical changes that could affect the results. When you check in at the desk you will be asked to deliver the specimen to the lab. REQUIRED VACCINES: Tdap is a tetanus diphtheria vaccine with Pertussis (whooping cough) that is now the recommended booster for teens and adults. Current recommendations state that anyone years of age should receive one dose. Chicken Pox vaccine (Varivax) is now mandatory for individuals 18 years and younger to receive two doses of the vaccine unless they have documented proof of having had chicken pox. RECOMMENDED VACCINES: Meningococcal (Menactra) vaccine is given to prevent specific types of meningitis prevalent in dormitory or communal settings. This formula is designed to work for up to 10 years and is recommended for year olds. HPV (Gardasil) human Papillomavirus vaccine prevents nine types of HPV which have a high incidence of causing cervical cancer and genital warts. It can be given to girls and boys between the ages 9-26 years. This is a three shot series given at 0, 2, and 6 months. Hepatitis B vaccine is a three dose series that is now given with baby shots. Most children will have had the series completed by this age. If they are not complete the series will be done at this time. The dosing schedule is 0, 1, and 6 months. If the child has received partial series it is not restarted. For inquiry of Vaccine and Administration fees please call our office. If you have questions regarding your child s vaccine needs please ask your physician. Rev 02/15

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3 1021 West 14 th Street P. O. Box 968 Hastings, Nebraska Appointments (402) Business (402) Fax (402) March 2017 SPORTS PHYSICALS In the past, Family Medical Center of Hastings has joined up with Mary Lanning Healthcare physicians to provide a free sports clinic. This year Family Medical Center will not be participating in this service. In accordance with recommendations by the American Medical Society of Sports Medicine, the physicians at our clinic agree that your child/children would benefit more by making an appointment to meet with their care provider for their sports physical/wellness exam. Performing a sports physical this way will help us to better ensure that your child/children are up to date on immunizations and to address sensitive topics with your child/children. Most insurance companies will pay 100% for preventive/wellness exams the sports physical would be included in this appointment. Please call your insurance company to see if your child/children would qualify. Special payment arrangements are available for students with insurance that does not cover wellness exams. We encourage you to schedule an appointment for your child/children well in advance prior to the school year. We look forward to seeing your child/children in the future! We re proud to support student athletes, and good luck with all your sports activities!

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5 Five-Two-One-Almost None Nemours Health and Prevention Services is committed to helping people understand the causes and implications of being at an unhealthy weight Almost None is our way to promote a healthier lifestyle for children and families. It s as simple as following these suggestions and tips for healthier eating and physical activity: Fruits and Vegetables Five stands for five or more servings of fruits and vegetables per day. Fruits and vegetables are packed with disease-fighting nutrients and give you energy, naturally. Hours of Screen Time Two stands for no more than two hours per day in front of a screen (TV, video games, and recreational computer time). A number of studies show a correlation between watching television and obesity. n Serve at least one fruit or vegetable at every meal and snack. Try all the different colors. n Dip veggies in low fat dressing. Tuck them in whole wheat pitas. Toss some on your pizza. n Try and try again. It may take children several tastings (10 or more) before they begin to enjoy certain foods. n Be a role model limit your own screen time. Play, take a walk, or cook with your kids instead. n Keep the TV in a central location and out of your child s bedroom. n Turn off the TV during dinner and take time to talk about your day. Hour of Physical Activity One means at least one hour of physical activity per day. Physical activity, especially when it gets the heart pumping faster, is vital to maintaining a healthy weight and overall good health. Kids who are raised in active families tend to stay active as adults. n Plan one physical activity for the family each weekend. Let each child take turns choosing the activity. n There are lots of ways to be active walking, dancing, gardening, and raking leaves can all get your heart pumping. n 10 minutes here, 10 minutes there and before you know it, you ve been moving your body for an hour. Sugary Drinks Almost none refers to almost no sugary beverages no more than two servings per week of soft drinks, sports drinks, and fruit drinks that are not 100% fruit juice. Over the last few decades, soda consumption has doubled for girls, tripled for boys. n Choose water. Add a lemon or lime wedge or a splash of juice for flavor. n Drink water, milk, and juice yourself. Your children learn by watching you. n Avoid bringing sodas and sports drinks home. If it s there, the kids will drink it. About NHPS Nemours Health and Prevention Services (NHPS), a non-profit organization based in Newark, Delaware, works with families and community partners to help children grow up healthy. Our goal is to drive long-term changes in policies and practices that promote child health and to leverage community strengths and resources to have the greatest impact on the most children. One of our initial areas of emphasis is childhood obesity prevention through promotion of healthy lifestyles, the centerpiece of which is the Almost None campaign. NHPS is the newest division of Nemours, one of the nation s largest pediatric health systems, operating the Alfred I. dupont Hospital for Children and outpatient facilities throughout the Delaware Valley and northern and central Florida. NHPS expands Nemours reach beyond clinical care to consider the health of the whole child within his or her family and community. Copyright 2007 The Nemours Foundation. All rights reserved.

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12 DENTAL EXAMINATION Is oral hygiene adequate? Number of restorations needed: Number of fillings present: Date(s) restorations to be completed: Recommendations: Signature DDS Date: SCHOOL VISION EVALUATION This form may be utilized by a Vision Specialist A School Vision Evaluation is required within six months prior to entering Nebraska Schools for the first time (Kindergarten or student transferring from Out of State). Name: Date: Student Status (check one): Beginner Grade Transfer from Out of State Required Tests* Pass Fail Amblyopia Strabismus Internal Eye Health External Eye Health Visual Acuity Right distance (20 ft.): 20/ aided/unaided Left distance (20 ft.): 20/ aided/unaided Right near (16 in.): 20/ aided/unaided Left near (16in.): 20/ aided/unaided *A vision evaluation consisting of these required tests meets the legal requirements for the State of Nebraska but is not a complete eye examination such as most eye doctors perform COMMENTS/RECOMMENDATIONS: Evaluation performed by (Signature) Office Phone Number: Date: 03/10

13 1021 West 14 th Street P. O. Box 968 Hastings, Nebraska Appointments (402) Business (402) Fax (402) PATIENT HEALTH QUESTIONNAIRE-2 (PHQ-2) Name Who is your regular Doctor Date of Birth Date Over the past 2 weeks, how often have you been bothered by any of the following problems? Not at all Several Days More than half the days Nearly every day 1. Little interest or pleasure in doing things Feeling down, depressed or hopeless Total = Negative Screen Positive Screen: Patient needs a follow up appointment for full Depression Testing.