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

3 to 5 Year 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 ASSESSMENTWNL ❒ YES ❒ NO (IF NO, DESCRIBE) ) WIC ❒ Yes ❒ No❒ Referred❒ FLUORIDE ❒ REFERREDPHYSICAL EXAMHEIGHT WEIGHT BLOOD PRESSUREAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.ExtremitiesSpineNeuroOther❒ DENTAL REFERRAL AGE 3 AND UP REQUIREDLAB TESTS❒ U/A ______ (5 yrs & as indicated)SENSORY SCREENNORMALVISION? ❒ REFERRED❒ YES ❒ NORESULTS:RIGHT _____ LEFT _____❒ LEAD SCREEN (blood @ 12 & 24 mo, @ 36-72 mo. if notscreened; verbal @ 6 mo-6 yrs)BOTH _____NORMALHEARING?DOES PARENT FEEL SPEECH & HEARING ARE NORMAL FOR AGE? ❒ YES ❒ NO❒ OTHER (specify, as indicated)❒ NORMAL ❒ ABNORMAL (RIGHT _____ LEFT _____) ❒ REFERREDDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE?❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ NO PLAYING WITH MATCHES ❒ SEAT BELTS ❒ STREET SAFETY❒ PRESCHOOL❒ SEXUAL CURIOSITYDIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003