Medicare Healthy Kids Ch    MBS Items 709 and 711 |

Patient details:
<<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>> Age: <<Patient Demographics:Age>>
Gender: <<Patient Demographics:Sex>>

Current contact details:
<<Patient Demographics:Full Address>>
Parent/Guardian names: <<Parent/Guardian names>>
Tel: <<Patient Demographics:Phone (Home)>>

Healthy Kids Check:
Explanation of Healthy Kids Check given: 
Consent for Check given: 
Date consent given:

Yes
Yes
<<Date consent given>>

Get Set 4 Life – habits for healthy kids:
Get Set 4 Life provided to Parent/Guardian:
Date provided:

Yes
<<Date Get Set 4 Life provided to parents/guardian>>

Signature of Parent/Guardian receiving 
Get 4 Life

......................................................................

Four year old immunisation:
Consent for immunisation given:
Date consent was given:

Yes
<<4 Yr old immunisation  date consent given>>

Signature of Parent/Guardian authorising consent for immunisation

...................................................................

If immunisation has previously been given note evidence:
Personal Health Record

Yes  No

Signature of Parent/Guardian authorising consent for immunisation

...................................................................

Vaccines:
<<Clinical Details:Immunisation List>>

Patient history:

Family and environmental factors:
Family relationships:

<<Patient History: Family relationships>>

Care arrangements: | <<Patient History: Care arrangments:>>
Other: |

Medical and social history:
Paediatrician:

<<Patient History: Paediatrician>>

Previous presentations: | <<Patient History: Previous Presentations>>
Social history: | <<Patient History: Social History>>

Lifestyle risk factors:
Eating Habits:

<<Patient History: Eating habits>>

Physical activity/inactivity: | <<Patient History: Physical activity/inactivity>>
Other: |

Patient's overall health status: | <<Patients overall health status:>>
Patients health issues identified and discussed with the patients parent or guardian: |
Recommended intervention and/or referrals | <<Recommended Intervention>>
GP or Practice Nurse: <<GP or Nurse Name>> |
Signature: ................................................................... | Date:.....................................................................

If the check has not been conducted at the patient’s usual medical practice, a copy of the record is to be sent to usual GP Practice:
Usual GP Practice: |

Parent/Guardian consent to provide a copy:

Date:

............................................................................

............................................................................

EXAMINATIONS AND ASSESSMENT (Mandatory from this point forward):
<<Clinical Details:Measurements>>
<<Clinical Details:Measurements>>

Identified Issues: | Actions:
<<Weight: Identified Issues>> | <<Weight: action taken>>

Check eyesight - including but not limited to:
•	conducting a visual inspection of the eyes
•	using the LEA Children’s Chart or similar, if appropriate
•	seeking parental/other concerns about vision (eg. amblyopia, squint, infection, injury)
•	questioning family history of eyesight problems

Visual acuity score (Right eye):  <<Visual acuity score (right eye)>>
Visual acuity score (Left eye):  <<Visual acuity score (Left eye)>>

Identified Issues: | Actions:
<<Eyesight: Identified Issues>> | <<Eyesight: Action taken>>

Check hearing - including but not limited to:
•	conducting an ear examination
•	seeking parental/other concerns regarding the child’s hearing or listening, following instructions or language
•	questioning any history of ear infections, ear discharge, recurrent or chronic otitis media
•	referring the child to an audiologist for a hearing assessment if appropriate

Identified Issues: | Actions:
<<Hearing: Identified Issues>> | <<Hearing: Action taken>>

Check oral health - teeth and gums (a potential tool could include Lift the Lip)
•	questioning whether the child has visited the dentist
•	questioning how often the child brushes their teeth

Identified Issues: | Actions:
<<Oral health: Identified Issues>> | <<Oral health: Action taken>>

Question toilet habits – including but not limited to:
•	questioning whether the child needs assistance or can use a toilet independently
•	questioning whether the child is a bed wetter

Identified Issues: | Actions:
<<Toilet habits: Identified Issues>> | <<Toilet habits: Action taken>>

Known or suspected allergies:
Identified Issues: | Actions:
<<Clinical Details:Allergies>> |

Current Progress Notes:
<<Summary:Progress Note (Current)>>

Question speech and language development - including but not limited to:
•	Speaks in sentences of five to six words / has basic concept of grammar <<5-6 word sentences>>
•	Tells stories <<Tells stories>>
•	Speaks clearly enough for strangers to understand <<Speaks clearly>>
•	Follows three part commands (ie pick the pencil up, draw a picture and give it to me) <<Follows 3 part commands>>
•	Engages in fantasy play <<Fantasy play>>

Identified Issues: | Actions:
<<Speech and language: Identified issues:>> | <<Speech: Action taken>>

Question fine and gross motor skills - including but not limited to:
•	picking up small objects <<Picks up small objects>>
•	drawing without scribbling <<Draws, not scriblles>>
•	walking, running, jumping, hopping, climbing stairs <<Walks, runs, jumps, hops, climbs stairs>>
•	riding a tricycle <<Rides a tricycle / bike>>

Identified Issues: | Actions:
<<Fine and Gross Motor skills: Identified issues>> |

Question behaviour and mood - including but not limited to:
•	sleeping <<Sleeps through>>
•	ability to separate from main carer for a short time without crying <<Separates from carer>>
•	able to share when asked <<Shares when asked>>

Identified Issues: | Actions:
<<Behaviour and mood: Identified issues:>> |

Other examinations considered necessary by GP/practice nurse

Examination: | Identified Issues: | Actions:

Medicare Healthy Kid's Check
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