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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<strong>Child</strong> <strong>Health</strong> <strong>Check</strong>-<strong>Up</strong> Coverage and Limitations Handbook<strong>Child</strong> <strong>Health</strong> <strong>Check</strong>-<strong>Up</strong>Initial Comprehensive <strong>Health</strong> and Developmental History FormPLEASE PRINTPERSONALNAME (Last) (First) ID DATEDATE OF BIRTH AGE ACCOMPANIED BY RELATIONSHIPCOMPREHENSIVE HEALTH AND DEVELOPMENTAL HISTORY (including physical and behavioral health development)ALLERGIESNoneCURRENT AND RELEVANT PAST MEDICATIONSNoneRELEVANT GROWTH AND DEVELOPMENT STATUSWNLMENTAL HEALTH STATUS*Normal forageSIGNIFICANT ILLNESSESNoneHOSPITALIZATIONS AND SURGERIESNoneRELEVANT FAMILY HISTORYNone* Providers based on medical discretion may use the Behavioral <strong>Health</strong> & Developmental Screening Form to determine the child’s behavioral healthstatus. If the child has a positive response to any of the questions on the tool, the child should be referred for further evaluation. See Appendix E inthe <strong>Child</strong> <strong>Health</strong> <strong>Check</strong>-<strong>Up</strong> Coverage and Limitations Handbook for the Behavioral <strong>Health</strong> & Developmental Screening Form. Providers mayphotocopy this tool for their use.ACHA-Medicaid/LD2003
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