Full Clinical Guidelines - Community First Health Plans.

CHILDREN’S SERVICES HANDBOOK
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Do you have any concerns about these things? ❑ Yes ❑ No
If you think your child may have a health problem, has he/she seen a doctor
or nurse about the problem? ❑ Yes ❑ No
Infants to 2 Years
❑ Is low weight or has a lot of weight
❑ Vomits (throws up) often
❑ Has eating problems
(poor appetite, eats non-foods)
Is anything causing your family stress right now? ❑ Yes ❑ No
Has this child or his/her parents been subject to neglect, physical, sexual, or
emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No
Treatment initiated? ❑ Yes ❑ No
Did the mother of this child use drugs or alcohol during the pregnancy? ❑ Yes ❑ No
Comments: (Please write anything else you want us to know about in this space.)
❑ Has sleeping problems (wakes a lot at night)
❑ Has little energy
Date: ____________
Signature: ______________________________________________________
Relation to patient: _______________________________________________
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