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

2 to 4 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 followingnormal? YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.Hip Abduc.ExtremitiesSpineNeuroOtherLAB TESTSSENSORY SCREENNORMAL VISION? (red reflex, follows) ❒ YES ❒ NO ❒ REFERREDDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE? (prone – lifts chest, hands atmidline, smiles spontaneously, rolls over one way, grasps rattle)❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ SOLID FOODS ❒ CHOKING, ASPIRATION ❒ FALLS❒ TEETHING ❒ BABY-PROOF HOME ❒ “BACK TO SLEEP”NORMAL HEARING? (i.e., smiles and/orturns toward speech or sound, coos)❒ YES ❒ NO ❒ REFERREDDIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003