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

9 to 13 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) ❒ FLUORIDE ❒ REFERREDPHYSICAL EXAMHEIGHT WEIGHT BLOOD PRESSUREAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.ExtremitiesSpineNeuroOtherLAB TESTS❒ DENTAL REFERRAL AGE 3 AND UP REQUIREDTanner Staging:SENSORY SCREENNORMALVISION? ❒ REFERRED❒ YES ❒ NORESULTS:RIGHT _____ LEFT _____BOTH _____NORMALHEARING?DOES PARENT FEEL SPEECH & HEARING ARE NORMAL FOR AGE? ❒ YES ❒ NODEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE?❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ DENTAL HYGIENE ❒ SEXUAL INFO ❒ BICYCLE SAFETY❒ PEER PRESSURE ❒ NUTRITION ❒ COMMUNICATION AFFECTION❒ SCHOOL PERFORMANCE ❒ SMOKING, ALCOHOL, DRUGS ❒ OTHER❒ NORMAL ❒ ABNORMAL (RIGHT _____ LEFT _____) ❒ REFERREDDIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003