Child Health Check-Up (formerly EPSDT) - Herman & Associates ...

1 to14 Day Child Health Check-Up Tracking FormPLEASE PRINTPERSONAL ! Periodic ! Interperiodic ! Parent/Caregiver RequestNAME (Last) (First) ID DATE OF BIRTHDATE AGE ACCOMPANIED BY RELATIONSHIPPRENATAL HISTORYFIRST PRENATAL VISIT DATE ALCOHOL, AMOUNT TOBACCO, AMOUNT STREET DRUGSSTDs (specify) HEPATITIS B HIV OTHER MATERNAL PROBLEMS PRESCRIBED MEDSWEEKS GESTATION! SVD ! CAESAREANBIRTH WEIGHTWHERE DELIVEREDPERINATAL HISTORYDEFORMITIES/APGAR ABNORMALITIES OTHER DATE OF D/C - LOSINTERVAL HISTORYPAST MEDICAL HISTORY WNL ❒ YES ❒ NO (IF NO, DESCRIBE)DEVELOPMENTAL HISTORY WNL ❒ YES ❒ NO (IF NO, DESCRIBE)BEHAVIORAL HEALTH STATUS WNL ❒ YES ❒ NO (IF NO, DESCRIBE)NUTRITIONAL ASSESSMENT❒ BREAST ❒ FORMULA: WIC ❒ YES ❒ NO ❒ REFERRED ❒ VITAMINS ❒ IRONPHYSICAL EXAMHEIGHT WEIGHT HEAD CIRCUMFERENCEAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomen inc. cordFem. PulseExt. Gen.Hip Abduc.ExtremitiesSpineNeuroOtherLAB TESTSSENSORY SCREENNORMAL VISION? (red reflex) ❒ YES ❒ NO ❒ REFERREDDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE? (prone – lifts head, moves arms/legsequally, moro reflex)❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONSNORMAL HEARING?(responds to noises, startles)❒ YES ❒ NO ❒ REFERREDDIAGNOSIS:PLAN:❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ INFANT CAR SEAT ❒ “BACK TO SLEEP” ❒ OTHERSIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003