Child Health Check-Up (formerly EPSDT) - Herman & Associates ...
Child Health Check-Up (formerly EPSDT) - Herman & Associates ...
Child Health Check-Up (formerly EPSDT) - Herman & Associates ...
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13 to 21 Year <strong>Child</strong> <strong>Health</strong> <strong>Check</strong>-<strong>Up</strong> 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.ExtremitiesSpineNeuroOther❒ DENTAL REFERRAL AGE 3 AND UP REQUIREDTanner Staging:LAB TESTS❒ Hgb/Hct ______ (9 mo, adolescent females & as indicated)SENSORY SCREENNORMALVISION?❒ YES ❒ NO❒ REFERREDDEVELOPMENT ASSESSMENTRESULTS:RIGHT _____ LEFT _____IS DEVELOPMENT NORMAL FOR AGE AND CULTURE?❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTBOTH _____NORMALHEARING?HEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ CAR/SEAT BELT SAFETY ❒ SEXUAL ED & STDs ❒ PHYSICAL ACTIVITY❒ PREGNANCY PREVENTION ❒ NUTRITION ❒ COMM. AFFECTION❒ MOTORCYCLE/ HELMET SAFETY ❒ SMOKING, ALCOHOL, DRUGS❒ SCHOOL PERFORMANCE ❒ BREAST OR TESTICULAR SELF-EXAM❒ OTHER (specify, as indicated)❒ NORMAL ❒ ABNORMAL (RIGHT _____ LEFT _____) ❒ REFERREDDIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003
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