DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health s. 252.04, Wis. Stats. F-42017 (Rev. 09/13) (608) 267-3733 FAX: (608) 266-0049 Page 1 of 6 WISCONSIN INITIAL REFUGEE HEALTH ASSESSMENT Client information is confidential under Wisconsin Statute 146.82(1) Please read instructions before completing this form. General Information (Review overseas medical documentation) Admission Status: Asylee Amerasian Cuban/Haitian Victim of Trafficking Refugee Immigrant Name - First, Middle, Last (include name suffix i.e. Jr. Sr. etc.) Alien or Visa Registration No. Race Date of Birth (mm/dd/yyyy) Sex Male Female U.S. Arrival Date Country of Origin Refugee Camp/Port of Entry Class B TB status: Class: B1 B2 B3 Class B, Other Specify: No No Yes (requires follow-up soon after arrival) Yes (requires follow-up soon after arrival) Family File number Resettlement agency (“VOLAG”) and contact person/telephone no. How will clinic be reimbursed for this screening? Medical Assistance Health Screening Contract Other Date of First Clinic Visit for Screening: Interpreter Needed? Yes No If yes, which language? Literate in own language? Yes No Vital Signs Height (in.): Weight (lbs): Head Circum(in.): BMI: (infants and children) BP: Pulse: Resp: Temp: Significant information from physical exam: Wheel chair/ mobility device Dialysis Oxygen Other: Vision and Hearing Screening (check all that apply) Vision Screening: Not done Wears glasses/contacts Hearing Screening: OD 20/ OS 20/ Normal Abnormal Uses aids Not done Oral Screening (check all that apply) Urgent Referral Early Referral Preventive Referral Oral Screening not done Cavities/caries present but no pain Apparent fillings present Cavities/caries present and pain present Periodontal disease signs present Apparent dental sealants Pain present in teeth and/or jaw with or without (redness, swelling and/or sores on gums, No apparent problems or dental biting/chewing and/or hard build-up on teeth) disease Open sores present in mouth or gums Comments:
DEPARTMENT OF HEALTH SERVICES Division of Public Health F-42017 (Rev. 09/13) STATE OF WISCONSIN s. 252.04, Wis. Stats. (608) 267-3733 FAX: (608) 266-0049 Page 1 of 6 WISCONSIN INITIAL REFUGEE HEALTH ASSESSMENT Client information is confidential under Wisconsin Statute 146.82(1) Please read instructions before completing this form. General Information (Review overseas medical documentation) Admission Status: Asylee Amerasian Cuban/Haitian Victim of Trafficking Refugee Immigrant Name - First, Middle, Last (include name suffix i.e. Jr. Sr. etc.) Alien or Visa Registration No. Race Date of Birth (mm/dd/yyyy) Sex Male Female U.S. Arrival Date Country of Origin Refugee Camp/Port of Entry Class B TB status: Class: B1 B2 B3 No Yes (requires follow-up soon after arrival) Class B, Other Specify: No Yes (requires follow-up soon after arrival) Family File number Resettlement agency (“VOLAG”) and contact person/telephone no. How will clinic be reimbursed for this screening? Medical Assistance Health Screening Contract Other Date of First Clinic Visit for Screening: Interpreter Needed? Yes No If yes, which language? Literate in own language? Yes No Vital Signs Height (in.): Weight (lbs): Head Circum(in.): (infants and children) BMI: BP: Pulse: Resp: Temp: Significant information from physical exam: Wheel chair/ mobility device Dialysis Oxygen Other: Vision and Hearing Screening (check all that apply) Vision Screening: Not done Wears glasses/contacts OD 20/ OS 20/ Hearing Screening: Normal Abnormal Uses aids Not done Oral Screening (check all that apply) Urgent Referral Oral Screening not done Cavities/caries present and pain present Pain present in teeth and/or jaw with or without biting/chewing Open sores present in mouth or gums Early Referral Cavities/caries present but no pain Periodontal disease signs present (redness, swelling and/or sores on gums, and/or hard build-up on teeth) Preventive Referral Apparent fillings present Apparent dental sealants No apparent problems or dental disease Comments:
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