DA Form 5223-R "Child Development Services (Cds) Child Health Assessment"

What Is DA Form 5223-R?

This is a military form that was released by the U.S. Department of the Army (DA) on July 1, 1989. The form, often mistakenly referred to as the DD Form 5223-R, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

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Download DA Form 5223-R "Child Development Services (Cds) Child Health Assessment"

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CHILD DEVELOPMENT SERVICES (CDS) CHILD HEALTH ASSESSMENT
For use of this form, see AR 608-10; the proponent agency is DCSPER.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, United States Code, Section 3013.
AUTHORITY:
Information is used by DA personnel to: (1) verify child health status and currency of immunization per admission
PRINCIPAL PURPOSE:
requirements: (2) note special program considerations or restrictions on child participation; (3) execute emergency
medical procedures for chronic illnesses/conditions; (4) refer child for enrollment in Exceptional Family Member
Program.
Information provided may be released IAW the Army's blanket routine uses contained in AR 340-21.
ROUTINE USES:
Disclosure of requested information is voluntary; however, if information is not provided, individuals may not be able to
DISCLOSURE:
participate in CDS programs.
NAME OF SPONSOR (Last, first, MI)
TELEPHONE (Home)
TELEPHONE (Duty)
NAME OF MEDICAL TREATMENT FACILITY/PHYSICIAN
ADDRESS (Include ZIP Code)
TELEPHONE
CHILD HEALTH INFORMATION (Sponsor)
NAME OF CHILD
BIRTH DATE
SEX
HAS CHILD BEEN UNDER REGULAR SUPERVISION OF A PHYSICIAN (If yes, explain circumstance(s) and current status)
YES
NO
YES
NO
HAS CHILD BEEN SCREENED FOR ENROLLMENT IN EXCEPTIONAL FAMILY MEMBER PROGRAM
IMMUNIZATION DATES (
List Month and Year)
DPT
TOPV
MMR
TINE
DISEASES AND ILLNESSES
(Check Yes, or No)
CHICKEN POX
YES
NO
RUBELLA
YES
NO
TEN-DAY MEASLES
YES
NO
MUMPS
POLIOMYELITIS
YES
NO
RHEUMATIC FEVER
YES
NO
YES
NO
SCARLET FEVER
YES
NO
OTHER (List)
CHRONIC ILLNESSES AND CONDITIONS
(Check Yes, or No)
VISION PROBLEMS
YES
NO
AUDITORY PROBLEMS
YES
NO
ORTHOPEDIC PROBLEMS
YES
NO
ASTHMA
YES
NO
DIABETES
YES
NO
SEIZURE DISORDER
YES
NO
OTHER (List)
ALLERGIES (List)
COMMENTS/INDICATE FREQUENCY
COLDS
EAR ACHES
STOMACH ACHES
HEADACHES
DA FORM 5223-R, JUL 1989
EDITION OF AUG 83 IS OBSOLETE
APD LC v2.01ES
CHILD DEVELOPMENT SERVICES (CDS) CHILD HEALTH ASSESSMENT
For use of this form, see AR 608-10; the proponent agency is DCSPER.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, United States Code, Section 3013.
AUTHORITY:
Information is used by DA personnel to: (1) verify child health status and currency of immunization per admission
PRINCIPAL PURPOSE:
requirements: (2) note special program considerations or restrictions on child participation; (3) execute emergency
medical procedures for chronic illnesses/conditions; (4) refer child for enrollment in Exceptional Family Member
Program.
Information provided may be released IAW the Army's blanket routine uses contained in AR 340-21.
ROUTINE USES:
Disclosure of requested information is voluntary; however, if information is not provided, individuals may not be able to
DISCLOSURE:
participate in CDS programs.
NAME OF SPONSOR (Last, first, MI)
TELEPHONE (Home)
TELEPHONE (Duty)
NAME OF MEDICAL TREATMENT FACILITY/PHYSICIAN
ADDRESS (Include ZIP Code)
TELEPHONE
CHILD HEALTH INFORMATION (Sponsor)
NAME OF CHILD
BIRTH DATE
SEX
HAS CHILD BEEN UNDER REGULAR SUPERVISION OF A PHYSICIAN (If yes, explain circumstance(s) and current status)
YES
NO
YES
NO
HAS CHILD BEEN SCREENED FOR ENROLLMENT IN EXCEPTIONAL FAMILY MEMBER PROGRAM
IMMUNIZATION DATES (
List Month and Year)
DPT
TOPV
MMR
TINE
DISEASES AND ILLNESSES
(Check Yes, or No)
CHICKEN POX
YES
NO
RUBELLA
YES
NO
TEN-DAY MEASLES
YES
NO
MUMPS
POLIOMYELITIS
YES
NO
RHEUMATIC FEVER
YES
NO
YES
NO
SCARLET FEVER
YES
NO
OTHER (List)
CHRONIC ILLNESSES AND CONDITIONS
(Check Yes, or No)
VISION PROBLEMS
YES
NO
AUDITORY PROBLEMS
YES
NO
ORTHOPEDIC PROBLEMS
YES
NO
ASTHMA
YES
NO
DIABETES
YES
NO
SEIZURE DISORDER
YES
NO
OTHER (List)
ALLERGIES (List)
COMMENTS/INDICATE FREQUENCY
COLDS
EAR ACHES
STOMACH ACHES
HEADACHES
DA FORM 5223-R, JUL 1989
EDITION OF AUG 83 IS OBSOLETE
APD LC v2.01ES
COMMENT/INDICATE FREQUENCY
DIARRHEA
CONSTIPATION
BED WETTING
SLEEP DIFFICULTIES
POOR EATING HABITS
TANTRUMS
EXCESSIVE ACTIVITY
DESCRIPTION OF SERIOUS CHRONIC ILLNESS/CONDITIONS
(Medical Staff)
ILLNESS/CONDITIONS
EARLY SYMPTOMS
RECOMMENDED CDS PROCEDURES
COMMENTS
ON-GOING MEDICATION
(Medical Staff)
TYPE
DOSAGE
FREQUENCY
CDS ADMINISTERED
MEDICAL STAFF COMMENTS
HEIGHT
WEIGHT
VISION
HEARING
SPECIAL MEDICAL CONSIDERATIONS
DESCRIBE ANY SPECIAL PROGRAM NEEDS, CONSIDERATIONS, OR RESTRICTIONS WHICH THE CHILD REQUIRES, IN ORDER TO
PARTICIPATE IN CDS PROGRAMS
REFERRAL FOR CHILD FIND SCREENING
YES
NO
MEDICAL STATEMENT
The above named child has been given a routine medical examination and has been found free of infectious or contagious diseases, and to be
capable of participating fully in CDS programs with the exception listed above.
SIGNATURE OF MEDICAL FACILITY REPRESENTATIVE
DATE
SIGNATURE OF SPONSOR
DATE
REVERSE OF DA FORM 5223-R, JUL 1989
APD LC v2.01ES
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