Street Medicine Health Screening Tool (Army Based)

PART B - IDENTIFICATION OF CHILD/YOUTH CONDITION/RESTRICTIONS
Any of the following conditions/restrictions: (Check yes or no)
1. Allergies
        No Yes (explain)
    a. Life threatening reaction
        No Yes (explain)
    b. Epi-pen required
        No Yes
    c. Other allergic reations (hives, rash, diarrhea) 
        No Yes
2. Asthma reactive airway disease
      No Yes (explain)
    a. Triggers exist for child's asthma attacks (stress, environmental, exercise) 
      No Yes (explain)
    b. Child routinely (greater than 10 days per month/four months per year) uses inhaled anti-inflammatory agents and/or bronchodilators
      No Yes (explain)
    c. Child has taken steroids during the past year (prednisone, prednisolone)
      No Yes (indicate number of days in past year)
Experienced unconsciousness or seizures associated with asthma attacks 
    No Yes (explain)
    e. Child required an urgent visit to emergency room or clinic for acute asthma within the last 12 months No Yes (indicate number of visits in the past year)
    f. Child has been hospitalized for asthma related condition in the past six months No Yes (explain)
    3. Attention Deficit Disorder (ADD)
No Yes
   a. ADD with hyperactivity
No Yes
   b. Is not well controlled with medication
No Yes (not well controlled)
   c. Behavioral/conduct concerns
No Yes (explain)
    4. Autism
  No Yes
 5. Behavioral/conduct concerns (for example, oppositional defiant disorder, anxiety disorder, school phobias) No Yes (explain)
    6. Blindness/visual problems
No Yes (explain)
    7. Diabetes
   No Yes (explain)
 8. Emotional problems that require care by a psychiatrist, psychologist or social worker No Yes (explain)
    9. Epilepsy
   No Yes (explain)
 10. Hearing problems
   No Yes (explain)
 11. Heart problems
   No Yes (explain)
 12. Kidney problems
   No Yes (explain)
 13. Speech/language delay
No Yes (explain)
    14. Physical disability
   No Yes (explain)
 15. Dietary restrictions
   No Yes (explain)
DA FORM 7625-1, MAY 2009
Page 2 of 3 APD LC v1.00ES
16. Assistance with activities of daily living
No Yes (explain)
17. Other conditions
No Yes (specify and explain)
Part C - Medications
Child is on medications on a regular basis
No Yes (If yes, please list medications and indicate which require administration during child care hours.)
Part D - Early Intervention and Special Education
Child has an Individualized Family Service Plan (IFSP), Individualized Education Plan (IEP) or 504 plan No Yes
Part E - Exceptional Family Member Program (EFMP) Enrollment
Child is enrolled in the EFMP