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

4 to 6 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 TESTS❒ LEAD SCREEN (blood @ 12 & 24 mo, @ 36-72 mo. if notpreviously screened; verbal @ 6 mo-6 yrs)❒ OTHER (specify, as indicated)SENSORY SCREENNORMAL VISION? (red reflex, coveruncovertest, follows)❒ YES ❒ NO ❒ REFERREDDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE? (prone–i.e., rolls over, reaches forobjects, laughs, squeals)❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ CUP, FINGER FOODS ❒ NO BOTTLE IN BED ❒ TEETHING❒ POOL & TUB SAFETY ❒ POISONS ❒ OTHERNORMAL HEARING? (i.e.,responds to sound, repeats sounds)❒ YES ❒ NO ❒ REFERREDDIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003