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

2 Weeks to 2 Month Child Health Check-Up Tracking FormPLEASE PRINTPERSONAL ! Periodic ! Interperiodic ! Parent/Caregiver RequestNAME (Last) (First) ID DATE OF BIRTHDATE AGE ACCOMPANIED BY RELATIONSHIPINTERVAL 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 ❒ IRON ❒ SOLIDSPHYSICAL EXAMHEIGHT WEIGHT HEAD CIRCUMFERENCEAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.Hip Abduc.ExtremitiesSpineNeuroOtherLAB TESTSSENSORY SCREENNORMAL VISION? (red reflex) ❒ YES ❒ NO ❒ REFERREDDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE ANDCULTURE? (prone – lifts head, moves arms/legsequally, regards face, moro reflex)IMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LIST❒ YES ❒ NO❒ REFERREDHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ INFANT CAR SEAT ❒ TALK TO BABY ❒ FEVER EDUCATION❒ SAFETY – ROLLING OVER ❒ OTHERNORMAL HEARING?(responds to noises, startles atloud noises)DIAGNOSIS:PLAN:SIGNATURE:❒ YES ❒ NO ❒ REFERREDFPS, FAFH, FMA, FOMA, AHCA-2003