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

6 to 12 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 ❒ ❒ VITAMINS ❒ IRONREFERREDSOLIDS❒ FLUORIDE ❒PHYSICAL EXAMHEIGHT WEIGHT HEAD CIRCUMFERENCEAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.Hip Abduc.ExtremitiesSpineNeuroOtherLAB TESTS❒ Hgb/Hct ______ (9 mo, adolescent females & as indicated)SENSORY SCREENNORMAL VISION? (red reflex,follows)❒ YES ❒ NO ❒ REFERREDDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE? (by 9 mo. Plays peek-a-boo, gets tositting, pulls self to stand, thumb-finger grasp, bangs two toys together; by 12 mo. Play pat-a-cake, neat pincergrasp, stands momentarily, walks holding on, points) ❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ BABY-PROOF HOME, POOL ❒ SELF-FEEDING ❒ TALK TO CHILD❒ TALK TO & NAME OBJECTS ❒ SLEEPING ❒ DISCIPLINE,PRAISE❒ SHOES-PROTECT, NOT SUPPORT❒ SUN PROTECTION ❒ OTHER❒ LEAD SCREEN (blood @ 12 & 24 mo, @ 36-72 mo. if notpreviously screened; verbal @ 6 mo-6 yrs)❒ DENTAL HYGIENENORMAL HEARING? (by 9 mo. Turns when called, listens to peopletalking, enjoys imitating sounds; by 12 mo. Responds to “no”, follows simplecommands, gives objects upon request, 1-3 words)DIAGNOSIS:PLAN:SIGNATURE:❒ OTHER (specify, as indicated)❒ YES ❒ NO ❒ REFERREDFPS, FAFH, FMA, FOMA, AHCA-2003