New Jersey Department of Health

CHILD HEALTH CONFERENCE ENCOUNTER RECORD

(Please write a brief narrative in each space.)	Date:

Recent Illness and Medication (Include any injuries and/or hospitalizations)

Allergies

Immunization Reactions

Growth and Development (Include Vision, Hearing, Speech and Language, Behavior)

24‑Hour

Food

Consumption
Vitamins (Fluoridated?)
Pica?
Total Fluids, Snacks
Feeding Technique
Sleep

Elimination
Urine (Stream? How many diapers in 24 hours?)
BM
Parents' Concerns

Observations (Include statement about parent/child interaction)

Topics Discussed (Nutrition, Injury Prevention, Oral Health Care, Etc., and Advice Given)

Due For

Signature of R.N.
Physical Examination (Use Flow Sheet of CH‑2)
Abnormal Findings
Recommendations (Prescriptions, Referrals, Immunizations)
M.D. Signature
Post Counseling

R.N./L.P.N. Signature
Name

RTC

CH-5

JUL 12

CH-5, Child Health Conference Encounter Record

ch-5, child health conference, encounter record, child and adolescent health

EWhite

2012-03-20

NJDOH