Lambeth NHS Primary Care Trust

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					Child’s Name and Date of Birth:
…………………………………………………………………………………………..




         SAFEGUARDING (CHILD PROTECTION) MEDICAL ASSESSMENT FORM
                           STRICTLY CONFIDENTIAL

I consent to a safeguarding medical assessment (which includes taking a history, full examination
and relevant investigations) being undertaken on ……………………………………………(name of
child) date of birth …………………

I understand that information from this report will be shared with professionals involved in the child’s
care and these may include the GP, social care, health visitor, school nurse, safeguarding teams and
the police.

Signature:
Name:
Relationship to child:
Date and time:

Hospital number:                                            NHS number:
Surname(S):
Forename(S):
DOB:
Age:
Gender: Male / Female
Current Address:
Type of placement: (Home/foster care etc)
Previous Address and dates:
Tel No:
Mobile number:
First Language:
Social Worker:                                              Tel No:
Social Worker Base/Address:
GP:                                                         Tel No:
School Nurse:                                               Tel No:
HV:                                                         Tel No:
School / Nursery:
Who has parental responsibility?
Subject to a child protection plan? Yes / No                Category:
Subject to a legal order? Yes/No                            Type:
Police Child Protection Team Involvement: Yes / No

Examination requested by:
Date And Time Of Request:
Date And Time Assessment Commenced:
Date And Time Assessment Completed:
Location Of Assessment:
Chaperone:
Who has consented and how?

Present At Medical:




Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                                   1
Child’s Name and Date of Birth:
…………………………………………………………………………………………..




Examining Doctors Details:

                                                                   Status:

                                                                   Status:

Consultant paediatrician responsible:




INFORMATION FROM REFERRAL AGENCY




HISTORY OF PRESENTING PROBLEM

History of incident given by child: (it is good practice to ask the child themselves what has happened,
without using leading questions. Verbatim documentation of both the questions asked and the
answers given is extremely useful)




Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                                   2
Child’s Name and Date of Birth:
…………………………………………………………………………………………..

Who was present when history recounted…………………………………………………………………

History reported by parent/carer:




Who was present when history recounted……………………………………………………………………..


DETAILED MEDICAL HISTORY OF CHILD:

PERINATAL HISTORY (Planned / Unplanned): …………………………………………………………….

Gestation: ……………………………………….. Place of Birth: ……………………………………………

Delivery: …………………………………………. Birth Weight: …………………………………………….

Neonatal History: ………………………………………………………………………………………………..




Feeding: …………………………………………………………………………………………………………..

Post Natal Depression: ………………………………………………………………………………………….



Developmental History:




Immunisations Completed – please list with dates
Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                                   3
Child’s Name and Date of Birth:
…………………………………………………………………………………………..


Previous Illnesses and hospital admissions:




A & E Attendances including accidents:


Known to Child Development Team Professionals?




Hearing:                                          Vision:

Current Medication:

Allergies:

EMOTIONAL & BEHAVIOURAL SYMPTOMS:

School Based Problems / Home Problems:



Self Harm:


Sexualised Behaviour:


Sleeping Pattern:


Eating Disorders:


Wetting / Soiling:


Primary / Secondary:
Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                              4
Child’s Name and Date of Birth:
…………………………………………………………………………………………..




SPECIFIC SYMPTOMS DESCRIBED BY CHILD: PRESENT / OR HISTORICAL

e.g. Headaches / Abdominal Symptoms:

Urinary Symptoms:

Bowel Symptoms:

Genital Soreness / Discharge:


Other:


MENSTRUAL HISTORY

Menarche:                        Cycle:                                 L M P:

Sanitary Protection:                                 Sexually Active:

FAMILY COMPOSITION


Natural Mother:                                                    Age:
Ethnicity:                       1st Language:                      Occupation:

Natural Father:                                                    Age:
                                   st
Ethnicity:                       1 Language:                        Occupation:

Married / Cohabiting / Separated / Divorced

Child’s Present Carers:

Language spoken at home: ……………………………………………………………………………………..

Other Adults contributing to Child Care:

Babysitters:


GENOGRAM: Include Siblings (including Step Children / Still Births / Childhood Deaths):




Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                                 5
Child’s Name and Date of Birth:
…………………………………………………………………………………………..




BACKGROUND HISTORY

Previous Social Services Involvement:




Is the child or siblings subject to a child protection plan:   Yes / No   Category:




FAMILY AND ENVIRONMENT

Race / Culture / Religion

Immigration Status (if relevant):

Social Isolation / integration:

Housing:




RELEVANT FAMILY HISTORY:

Parents / Step Parents / Wider Family:


General Health:


Emotional / Psychological Health:


Medication:


History of Care System:


Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                                      6
Child’s Name and Date of Birth:
…………………………………………………………………………………………..
Drugs / Alcohol:


Domestic Violence:




PARENTING CAPACITY:


Basic Care:



Stimulation:



Emotional Warmth:



Ensuring Safety:



Guidance & Boundaries:


Any other information:




Examining Doctor: …………………………………………. Date of Attendance: ………….……
                               7
Child’s Name and Date of Birth:
…………………………………………………………………………………………..

GENERAL EXAMINATION


Height:                    Centile:            Weight:             Centile:
Head Circumference:                            Centile:


Comparisons to previous growth measurements:



General Appearance/clothes:



Emotional State / Demeanour:



Cleanliness, including hair, nails, nappies:


Nutrition:                                     Teeth:

Tanner staging:

Head / Neck / Mouth:                           Frenuli:

ENT:                                           Mucous Membranes:

Eyes:

Respiratory System:

Cardiovascular System:

Abdomen:

Central Nervous System:

Development:




Skeletal:

Observation of carer interaction in clinic:




Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                                     8
Child’s Name and Date of Birth:
…………………………………………………………………………………………..




Examining Doctor: …………………………………………. Date of Attendance: ………….……
                               9
Child’s Name and Date of Birth:
…………………………………………………………………………………………..




Examining Doctor: …………………………………………. Date of Attendance: ………….……
                               10
Child’s Name and Date of Birth:
…………………………………………………………………………………………..


GENITAL INSPECTION – GIRLS Tick to acknowledge verbal consent for examination obtained □

Manner of Child:                                 Position for Examination:

External Genitalia (Pre, Peri, Post Pubertal):

Vulva:                                           Introitus:

Labia Majora / Minora:


Clitoris:                                        Urethra:

Posterior Fourchette:

Hymen:       Edge:
             Opening:


GENITAL INSPECTION – BOYS Tick to acknowledge verbal consent for examination obtained □

Manner of Child:                                 Position for Examination:

Genitalia (Pre, Peri, Post Pubertal):

Penis:                                           Foreskin:

Glans:

Testicles:


ANAL INSPECTION


Position for Examination:

Anus and perianal area:


Veins:                                  Dilatation:                          Length of Time:



SUMMARY OF SAFEGUARDING MEDICAL:




Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                                       11
Child’s Name and Date of Birth:
…………………………………………………………………………………………..
OPINION:




Information Given to Child’s Carers / Social Worker:




HEALTH RECOMMENDATIONS:


Further investigation:

Follow up:

Other Referrals/Examination of siblings required:

Specific appointments needed:


FURTHER INVESTIGATION

Blood Tests:




Swabs:
X-Rays:
Urine:
Photography:



CONSENT FOR PHOTOGRAPHS TO BE TAKEN

I have agreed for my child to be photographed. All photographs will only be used in an appropriate
context and may be provided to other professionals if deemed by the Trust to be in the child’s best
interest.


Signed …………………………………………………….. Date …………………………………….


Name ………………………………………………………
(please print)


Examining Doctor: …………………………………………. Date of Attendance: ………….……
                                                    12
Child’s Name and Date of Birth:
…………………………………………………………………………………………..

Examining doctors signature and print name ……………………………………………………….
Date:                                   ……………………………………………………………


Examining doctors signature and print name ……………………………………………………….
Date:                                   ……………………………………………………………


Consultants signature and print name                ……………………………………………………………
Date:                                               ……………………………………………………………

Can this report be submitted for case conference? YES/NO

The contents of this report can be shared only for the purposes of child protection in accordance with Article 3 of the
Human Rights Act with respect to the child in question, paragraphs 36-39 of the General Medical Council publication
“Confidentiality: Protecting and Providing Information” and the general provisions of the 1989 Children Act. Attendees
at Case Conference should return any copies to the Case Conference Chair at its conclusion.

CIRCULATION LIST:

Please tick and name the individuals to whom the report has been sent to:

GP
Named nurse for safeguarding
Named doctor for safeguarding
Children’s Social Care team
Health visitor
Police
File copy (be clear as to which notes copies need to go into)
Other




Examining Doctor: …………………………………………. Date of Attendance: ………….……
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