Texas HealTH sTeps - Fostercare Texas

Texas Health Steps 

Child Health Record Forms 

These forms are intended to assist providers 

in documenting all required components of the 

Texas Health Steps medical checkup. 

Online Forms 

http://www.dshs.state.tx.us/thsteps/forms.shtm 

02/2012

Free CE credits. Available 24/7. 

Now you can choose the time and place to take the courses you need and want. 

We’ve made it easy to take free CE courses online. We offer 24/7 access to more 

than 40 courses, including when to refer to a pediatric specialist. And even when you’re 

not taking a course, you can access the latest references and resources you need. 

The CE courses were developed by the Texas Department of State Health 

Services and the Texas Health and Human Services Commission. All courses are 

comprehensive and accredited. * 

*Accredited by the Texas Medical Association, American Nurses 

Credentialing Center, National Commission for Health Education 

Credentialing, Texas State Board of Social Worker Examiners, 

Accreditation Council of Pharmacy Education, UTHSCSA Dental 

School Office of Continuing Dental Education, Texas Dietetic 

Association, Texas Academy of Audiology, and International 

Board of Lactation Consultant Examiners. Continuing Education 

for multiple disciplines will be provided for these events. 

Taking New Steps 

To view courses online, visit www.txhealthsteps.com. 

CE Courses Include: 

• When to Refer to a Geneticist 

• Children with Diabetes 

• Children with Asthma 

• Newborn Screening 

• Case Management 

• Developmental Screening 

• Many others 

Referral Guidelines 

• Pediatric Depression 

• High Blood Pressures 

in the Office 

• Atopic Dermatitis 

• Gastroesophageal Reflux 

in Infants 

• Exercise-Induced Dyspnea 

• Referral Guidelines Overview 

2/2012 OPE001

How to Complete thE 

Texas Health Steps 

Checkup Forms 

The Texas Health Steps (THSteps) checkup forms serve as a complete documentation tool for each 

specific age (excluding the newborn examination) on the Texas Health Steps Periodicity Schedule. 

The use of these forms is not mandatory for THSteps providers, but the forms will assist the providers 

in assuring documentation of all required components of a THSteps medical checkup. 

The front side of each form includes areas of documentation 

for the federally mandated components of the checkup, 

including “History,” “Immunizations,” “Laboratory,” “Unclothed 

Physical Examination,” and “Health Education Including 

Anticipatory Guidance.” There is also space available for 

“Assessment” of the current checkup and any follow-up 

planning and/or recommended referrals to other providers. 

Beginning at 6 months of age, the form also includes space for 

the required dental referral. 

These instructions are organized by each mandated 

component. Not all items on the forms are included in these 

instructions, as some items are self-explanatory. Items that are 

not required for a specific age checkup are not included on the 

form for that age. 

A notation should be made in each area using the check 

boxes or lines provided and space, if needed, to elaborate 

on findings. If using the forms in an electronic format, the 

spaces are able to be edited and may have a blue shading 

that shows over some sections. If that happens and is not 

wanted, click on the “Highlight Existing Fields” box in the 

upper right-hand corner, and the blue shading will disappear 

but the editing feature will remain. The tab feature will move 

the cursor through the form. If notations are not made on the 

form, supplemental documentation must be maintained in the 

medical record. The provider may write “N/A” if not applicable, 

use the symbol “Ø” for “None noted,” or write “None.” In areas 

with a Y (Yes) or N (No) or a P (Pass) or F (Fail) check box , 

check one of the boxes and notate findings, if appropriate, in 

the space provided. If there is a box for a section heading, 

check the box if any item(s) was/were addressed. 

Demographics 

Complete the patient demographic section for each periodic 

checkup: 

Name = the patient’s name 

Medicaid ID = the patient’s Medicaid number 

DOB = the patient’s date of birth 

Primary Care Giver = the name of the person whom 

the patient lives with and who provides care of the patient 

Gender = the gender of the patient 

Phone = the telephone number where the Primary Care 

Giver may be reached for contact 

Date of Service = the date of the checkup 

Informant = the name of the person accompanying the 

patient and who is giving and receiving the information 

needed on the patient’s history and the Health Education 

and Anticipatory Guidance 

NAME: 

DOB: 

GENDER: MALE FEMALE 

DATE OF SERVICE: 

hiStorY 

MEDICAID ID: 

PRIMARY CARE GIVER: 

PHONE: 

INFORMANT: 

uNClothEd phYSiCal ExaM 

02/2012 

See new patient history form 

iNtErVal hiStorY: 

NKDA Allergies: 

Current Medications: 

– 1 – 

See growth graph 

Weight: ( %) Height: ( %) 

BMI: ( %) Heart Rate: 

Blood Pressure: / Respiratory Rate: 

Temperature (optional): 

Normal (Mark here if all items are WNL) 

Abnormal (Mark all that apply and describe): 

ECord

HISTORY 

UNC 

Left side of the front of the checkup form 

HISTORY 

A comprehensive health and developmental history is a 

federally mandated component of the medical checkup and 

must be completed at every checkup. 

A comprehensive new patient personal and family history form 

of the provider’s choosing is completed at the initial checkup as 

NAME: 

a separate form. It must be retained in the medical record for 

reference DOB: at future checkups. For the initial checkup, this box 

may GENDER: be checked without the need for further completion of the 

interval DATE history OF section. SERVICE: The box is checked at all subsequent 

checkups to indicate there is a comprehensive new patient 

personal and family health history completed and in the record. 

HISTORY 


NAME: 

INTERVAL 

DOB: 

HISTORY: 

If the NKDA Allergies: 

NAME: 

initial comprehensive personal and family health history 

GENDER: 

was completed previously and is in the record, it is not 

DOB: 

required 

DATE 

Current 

to 

OF 

be 

Medications: 

completed 

SERVICE: 

at subsequent checkups. 

GENDER: 

INTERVAL HISTORY 

DATE OF HISTORY: SERVICE: 

This Visits section to other is completed health-care as an providers, interim history facilities: to supplement 

the initial See history new patient and includes history form 

HISTORY 

documentation of mental 

health, INTERVAL developmental, HISTORY: nutritional, and tuberculosis screening. 

It also Parental 

See NKDA includes new 

concerns/changes/stressors 

patient items Allergies: that history may form have changed in family since or home: the 

comprehensive INTERVAL personal HISTORY: and family health history was 

recorded 

Psychosocial/Behavioral 

or may include additional 

Health 

information 

Issues: Y 

that 

N 

would 

Current 

NKDA 

Medications: 

Allergies: 

impact Findings: the current checkup. 

Current 

Visits to 

Medications: 

other health-care providers, facilities: 

Lead questionnaire, risk identified: Y N 

TB questionnaire*, risk identified: Y N 

List Visits *TB Parental all known skin to other 

concerns/changes/stressors test visits if health-care indicated to hospitals, providers, other PPD providers facilities: 

in family placed such or home: as 

specialists, (See back primary for care forms) physician (PCP) if this checkup is not 

performed by the PCP, or facilities, such as radiology or other 

Parental DEVELOPMENT: 



Health Issues: 

in family 

Y 

or 

N 

home: 

outpatient facilities. 

Use Findings: of standardized tool: P F 

ASQ* ASQ-SE* PEDS* Other: 

Psychosocial/Behavioral *ASQ, ASQ-SE, PEDS, required Health for Issues, use as of including 9/1/11 

Maternal 

Lead questionnaire, 

Depression: Y 

risk identified: 

N 

Y N 

Findings: 

TB questionnaire*, risk identified: Y N 

*TB NUTRITION*: skin test if indicated PPD placed 

Problems: (See back Y for forms) N 

Mental 

DEVELOPMENT: 

Assessment: 

health screening of the patient is required as part of 

• Gross and fine motor development 

the comprehensive 

DEVELOPMENT: 

history. In early infancy, the possibility of 

• Communication skills/language development 

maternal Use • Self-help/care of depression standardized should skills tool: be considered, P since F this could 

impact *See ASQ* • the Social, Bright infant’s Futures ASQ-SE* emotional health. Nutrition development 

Document PEDS* Book if needed findings, Other: if any, as space 

allows, *ASQ, • on Cognitive ASQ-SE, the form development 

PEDS, or on required additional for paper use as as of 9/1/11 needed. 

IMMUNIZATIONS 

• Mental health 

NUTRITION*: 

Up-to-date 

NUTRITION*: 

Problems: Deferred Y - Reason: N 

Assessment: Breastmilk 

Min per feeding: Number of feedings in last 24 hrs: 

Given 

Formula 

today: 

(type) 

DTaP HAV HBV HIB IPV 

Oz *See Meningococcal 

per Bright feeding: Futures Nutrition Number 

MMR Book of if feedings needed Pneumococcal 

in last 24 hrs: 

Water 

Varicella 

source: 

MMR-V HIB-HBV 

fluoride: Y 

DTap-HIB 

N 

IMMUNIZATIONS 

Solids 

DTaP-HB-IPV DTaP-IPV-HIB Influenza 

02/2012 

– 2 – 


INTERVAL 

NAME: 

HISTORY: 

NKDA Allergies: 

DOB: 

Lead risk assessment should be done beginning at six months 

through 

GENDER: 

six years through 

MALE 

anticipatory 

FEMALE 

guidance. The back of 


the form DATE contains OF SERVICE: questions related to lead risk factors and 

information about Form Pb-110, Lead Risk Questionnaire. 

Visits hiStoRY 

other health-care providers, facilities: 

The form is available at 

http://www.dshs.state.tx.us/thsteps/forms.shtm See new patient history and may 

be completed Parental concerns/changes/stressors for reporting purposes and in faxed family or or mailed home: 

inteRVal hiStoRY: 

as noted 

NKDA 

on the bottom 

Allergies: 

of the form to the Department of 

MEDICAID State Health ID: Services (DSHS) Lead Program for every child 

PRIMARY screened, 


whether CARE GIVER: or not the 

Health 

results 

Issues: 

show a 

Y 

risk of 

N 

lead 

Findings: Current Medications: 

PHONE: exposure. Blood lead screening is required at 12 and 24 

INFORMANT: 

months. 

Visits Lead to questionnaire, other health-care risk providers, identified: facilities: Y N 

NAME: TB questionnaire*, risk identified: Y N 

UNCLOTHED PHYSICAL EXAM 

DOB: *TB skin test if indicated PPD placed 

See Parental (See back 

growth concerns/changes/stressors for forms) 

GENDER: graph MALE FEMALEin family or home: 

MEDICAID ID: 

Weight: 

Screening DATE DEVELOPMENT: 

OF for tuberculosis SERVICE: 

PRIMARY CARE 

( 

GIVER: 

%) 

(TB) 

Height: 

is a required part 

( 

of the 

%) 

history 

BMI: at certain Use of ages. standardized ( The questions %) tool: Heart contained Rate: in P the THSteps F TB 

Blood MEDICAID PHONE: questionnaire 


Pressure: ID: are located / on 

Health 

Respiratory the back 

Issues: 

of Rate: 

Y 

checkup 

N 

ASQ* ASQ-SE* PEDS* Other: forms 

Temperature: 

PRIMARY INFORMANT: 

for specific 

hiStoRY 

Findings: 

*ASQ, ASQ-SE, ages CARE and PEDS, GIVER: can required serve as for documentation use as of 9/1/11 for TB 

PHONE: screening. Normal See (Mark new patient here if history all items form are WNL) 

Abnormal UNCLOTHED INFORMANT: inteRVal NUTRITION*: (Mark all hiStoRY: PHYSICAL that apply and describe): EXAM 

Appearance Problems: NKDA deVelopMental Y N Allergies: Nose SCReeninG: Lungs 

Head See Assessment: growth graph Mouth/throat Abdomen 

UNCLOTHED 

Use of standardized 

Weight: Skin PHYSICAL 

tool: P 

( Teeth EXAM 

F 

%) Height: Genitalia 

Current ASQ Medications: PEDS 

( %) 

BMI: Eyes ( %) Neurological Heart Rate: Extremities 

See Autism 

Blood Ears 

growth screening: graph P F 

*See Pressure: M-CHAT Bright Futures / Nutrition Heart Respiratory Book if needed Rate: Back 

Weight: 

Temperature: 

Visits to other ( health-care %) providers, Length: facilities: Musculoskeletal ( %) 

Head Abnormal IMMUNIZATIONS 

Circumference: findings: ( %) 

Heart Normal Rate: (Mark here if all items Respiratory are WNL) Rate: 

Temperature: 

Abnormal 

Developmental Parental nutRition*: concerns/changes/stressors 

(Mark 

surveillance 

all that apply 

through 

and describe): 

6 years in family of age or is home: 

Up-to-date 

required 

as Appearance part Breast Bottle Cup 

Normal Deferred of the history, 

(Mark- here Reason: with 

if Nose use of a validated 

all items are WNL) Lungs and standardized 

developmental Head Psychosocial/Behavioral Milk (%): screening Mouth/throat tool Health Ounces specific Issues: per ages. day: 

Abdomen Y Check N the box in 

Abnormal Additional: Solid foods: 

front Skin Findings: of the 

(Mark 

tool used. 

all that 

Teeth 

apply and describe): 

Genitalia 

Teeth Appearance Juice: 

Eyes Given # today: DTaP Nose 

Neurological HAV HBV Abdomen 

Extremities HIB IPV 

OrHead/fontanels Water source: 

Ears 

Mouth/throat 

Heart 

Genitalia fluoride: Y N 

Meningococcal MMR Back Pneumococcal 

Visual Skin Varicella Acuity Screening: MMR-V Neurological HIB-HBV Extremities 

Musculoskeletal DTap-HIB 

OD Abnormal 

Eyes *See deVelopMental / Bright Futures 

findings: OS Heart/pulses Nutrition / Book OU if needed 

DTaP-HB-IPV DTaP-IPV-HIB 

SuRVeillanCe: Back / Influenza 

Hearing Ears • Gross Checklist and for fine Parents: Lungs motor development 

P F Musculoskeletal 

(See LABORATORY 

iMMunizationS 

• Communication back for form) skills/language development Hips 

Abnormal • Self-help/care findings: skills 

Up-to-date 

HEALTH • Up-to-date Social, EDUCATION/ANTICIPATORY 

emotional development 

Deferred Reason: 

Additional: GUIDANCE • Deferred Cognitive 

(See - Reason: development 

back for useful topics) 

Teeth 

• Mental 

# 

health 

Selected Given today: health topics DTaP addressed Hep A in Hep any B of the Hib IPV 

Additional: 

Visual following nutRition*: 

Ordered Acuity MMR areas*: Screening: today: PCV Meningococcal* Varicella 

Subjective At ages that 

OD • School MMRV / 

Vision do not 

Readiness 

Screening: require a standardized 

OS DTaP-Hib • / Nutrition 

P 

OU DTaP-IPV-Hep F screening tool, the 

Breast Bottle Cup / B 

Hearing checkup 

Hearing • Development DTaP-IPV/Hib 

Checklist must include 

Checklist 

for 

for 

Parents: a review 

Parents: • Safety Influenza 

of 

P 

P milestones 

F 

F as listed on the 

Milk (%): 

Ounces per day: 

form. (See 

•(See Physical 

back 

back 

for 

Activity for 

form) 

Solid 

Check 

*Special foods: 

the 

populations: form) box in front of “Developmental Surveillance” 

See ACIP 

to document Signature/title 

Juice: review of milestones. 

HEALTH ASSESSMENT 

Water laboRatoRY 

source: EDUCATION/ANTICIPATORY 

fluoride: Y N 

GUIDANCE (See 

(See 

back 

back 

for 

for 

useful 

useful 

topics) 

topics) 

*See Tests Bright ordered Futures today: Nutrition Book if needed 

Selected 

Selected 

Hgb/Hct 

health 

health 

topics 

topics 

addressed 

addressed 

in 

in 

any 

any 

of 

of 

the 

the 

following 

following areas*: 

areas*: 

• Parental/Maternal iMMunizationS 

School Readiness 

Well-Being 

• Nutrition 

• Nutritional Adequacy 

• Infant 

Development 

Behavior 

• Safety 

• Safety 

• Infant-Family 

Physical Up-to-date Activity 

Harmony 

Deferred - Reason: 

ASSESSMENT 

PLAN/REFERRALS 

ASSESSMENT 

Signature/title 

Dental Given Referral: today: Y DTaP Hep A Hep B Hib IPV 

ISIT CHILD CHILD HEALTH HEALTH CHILD RECORD HEALTH RECORD RECORD 

See 

Weigh 

MEDI 

BMI: 

Blood PRIM 

Tempe PHON 

INFO Nor 

Abnor 

unC App 

Hea 

Skin See 

Eye 

Weigh Ears 

Head 

Abnor Heart R 

Tempe 

Nor 

Abnor 

App 

MEDIC Additio 

Hea 

PRIMA 

Teeth 

Skin 

PHON Eye 

Visual 

Ears 

INFOR OD 

Nos 

Hearin 

(Se 

unCl Abnor 

HEAL 

See 

GUID 

Weigh 

Head SeleC 

Heart followi R 

Tempe 

Subjec • Sc 

Subjec Norm • De 

• Ph 

Abnorm 

heal 

ASS Appe 

Guid Hea 

Skin 

Eyes Sele 

follow Ears 

Nose • Fa 

Abnorm • De 

• Co 

*See B 

PLAN 

Denta 

aSS 

Other 

Subjec 

Return 

Subjec 

heal plan 

Guid 

Denta 

Signatu Other Sele 

followi 

• De 

Return • Be 

• Ro 

*See Br 

aSSe 

Signatu

DPAP-IPV DTaP-HB-IPV DTaP-IPV-HIB Influenza 

Current Maternal Medications: Depression: Y N 

Normal (Mark here if all items are WNL) 

Findings: 

Abnormal LABORATORY 

(Mark all that apply and describe): 

Visits to other health-care providers, facilities: 

Appearance Nose Lungs 

DEVELOPMENT: 

Additional: Head 

Up-to-date 

Mouth/throat Abdomen 

• Gross and fine motor development 

Subjective Skin 


Vision Screening: Teeth P F Genitalia 

Document Parental • Communication 

abnormal concerns/changes/stressors findings 

skills/language 

and action 

development in family taken for home: both the Hearing that Eyes are Checklist ordered. for Separate Parents: Neurological forms P indicating F Extremities laboratory tests 

• Self-help/care skills 

standardized screenings and the review of milestones in the ordered/results 

Ears (See back for form) Heart Back 

• Social, emotional development 

Ordered today: also serve as sufficient documentation. 

Musculoskeletal 

space • Cognitive provided development 

or on additional paper as needed. Referral 

Psychosocial/Behavioral Health Issues: Y N 

Abnormal 

for further • Mental assessment health can be documented in the “Plan/ HEALTH findings: EDUCATION/ANTICIPATORY 

Findings: 

Referrals” section. 

GUIDANCE (See back for useful topics) 


Selected health topics addressed in any of the 

NUTRITION*: 

Lead questionnaire, risk identified: Y N 

Additional: 


TB Breastmilk questionnaire*, risk identified: Y N 

Teeth The person # completing the checkup and the staff assisting 

• Parental/Maternal Well-Being • Nutritional Adequacy 

*TB Min per skin feeding: test if indicated Number of feedings PPD placed in last 24 hrs: in completion of the checkup sign on the line with their title 

• Infant Behavior 

• Safety 

(See Formula back (type) for forms) 

Audiometric included. Screening: 

• Infant-Family Harmony 

Oz per feeding: Number of feedings in last 24 hrs: R 1000Hz 2000HZ 4000HZ 

Water source: fluoride: Y N L 

ASSESSMENT 

Right 1000Hz side of the 2000HZ checkup form4000HZ 

DEVELOPMENT: 

Solids 

NAME: 

MEDICAID ID: 

Use of standardized tool: P F 

Visual Acuity Screening: 

*See ASQ* Bright DOB: Futures ASQ-SE* Nutrition PEDS* Book if needed Other: 

OD Unclothed PRIMARY / CARE OS Physical GIVER: / OU Exam/ 

*ASQ, GENDER: ASQ-SE, PEDS, required for use as of 9/1/11 

A comprehensive PHONE: unclothed physical examination including a 

ORIMMUNIZATIONS 

HEALTH EDUCATION/ANTICIPATORY 

DATE OF SERVICE: 

graphic INFORMANT: recording over time of measurements for comparison 


NUTRITION*: 

Up-to-date 

to national norms for the patient’s age is a federally required 

Problems: Deferred Y - Reason: 

component of the checkup. 

HISTORYN 

Selected UNCLOTHED health topics PHYSICAL addressed in any EXAM of the 

Assessment: 

NAME: 

following MEDICAID areas*: ID: 


• School See Readiness/Limitations 

growth graph 

• Nutrition 

Given DOB: NAME: today: DTaP HBV HIB IPV 

• Personal PRIMARY Hygiene 

• Safety 

*See Pneumococcal Bright INTERVAL Futures Nutrition HISTORY: 

MEDICAID CARE 

HIB-HBV Book if needed DTap-HIB PLAN/REFERRALS 

Weight: ID: GIVER: 

( %) Height: ( %) 

GENDER: 

Rotavirus DOB: NKDA 

DTaP-IPV-HBV 

Allergies: 

Check PHONE: 

DTaP-IPV-HIB Other PRIMARY BMI: the box CARE to ( indicate GIVER: %) the growth Heart graph Rate: has been 

IMMUNIZATIONS 

Referral(s): 

ASSESSMENT 

DATE completed Blood Pressure: and measurements / are Respiratory notated on Rate: the graph 

GENDER: OF SERVICE: 

INFORMANT: 

PHONE: 

Nutrition screening is a required part of the history. For younger 

LABORATORY 

NAME: 

retained MEDICAID Temperature: in the record. ID: Resources for growth may be found 

ages, Up-to-date notate DATE Current the OF Medications: 

type SERVICE: of nutrition and the amount received as at http://www.dshs.state.tx.us/thsteps/forms.shtm. 

INFORMANT: 

Normal (Mark here if all items are WNL) The 

appropriate. Up-to-date Deferred HISTORY 

DOB: 

For - Reason: ages without an age-specific nutrition review, 

UNCLOTHED PRIMARY CARE PHYSICAL GIVER: EXAM 

measurement area provided for notating during the visit is 

check Deferred the GENDER: Y or - N Reason: box assessed and notate any appropriate Return PHONE: Abnormal to office: (Mark all that apply and describe): 

HISTORY 

Visits See to new other patient health-care history form 

then UNCLOTHED optional 

providers, facilities: 

See Appearance growth for use. graphPHYSICAL Nose EXAMLungs 

findings DATE in the “Assessment” space in this section. If needed 

Ordered Given INTERVAL NAME: 

OF SERVICE: 

INFORMANT: 

today: today: DTaP HAV HBV HIB IPV 

Head Mouth/throat Abdomen 

for completion See new of this patient HISTORY: 

item, history refer to form 

Weight: MEDICAID ID: 

Bright Futures at http://www. See 

Meningococcal Other 

MMR Pneumococcal 

Skin 

growth graph ( %) Length: ( %) 

DOB: NKDA Allergies: 

BMI: PRIMARY ( CARE %) GIVER: Head Teeth Circumference: Genitalia ( %) 

brightfutures.org/nutrition 

Varicella HISTORY 

INTERVAL Parental concerns/changes/stressors MMR-V HISTORY: as indicated 

HIB-HBV 

by the in asterisk. family DTap-HIB or home: PLAN/REFERRALS 

UNCLOTHED Heart Weight: Eyes Rate: ( PHYSICAL Neurological %) Respiratory Length: EXAMExtremities 

( %) 

GENDER: 

DPAP-IPV NKDA MALE 

DTaP-HB-IPV Allergies: FEMALE 

DTaP-IPV-HIB Influenza The 

BMI: PHONE: 

Rate: 

Temperature: form 

Ears 

allows 

( 

space 

%) 

for 

Head Heart 

documenting 

Circumference: 

the physical 

Back ( %) 

Current 

Immunizations 

DATE See new OF Medications: SERVICE: patient history form 

Dental Heart INFORMANT: 

See Referral: Rate: growth Y graph Respiratory Rate: Musculoskeletal 

Signature/title LABORATORY 

Psychosocial/Behavioral Health Issues: Y N Signature/title 

Other examination 

Temperature: 

Abnormal Referral(s) Normal and (Mark findings. 

findings: here if all items are WNL) 

Age-appropriate 

INTERVAL Current Medications: 

Findings: screening 

HISTORY: 

and administration of 

Weight: ( %) Length: ( %) 

Visits to other health-care providers, facilities: 

Abnormal Normal (Mark here all that if all apply items and are describe): 

immunizations hiStorY NKDA Allergies: 

BMI: 

Up-to-date according to the schedule established by uNClothEd ( %) WNL) 

Appearance phYSiCal Head Circumference: 

Nose ExaM ( %) 

the Advisory Deferred 

Visits Committee to 

- Reason: 

other health-care on Immunization providers, Practices facilities: (ACIP) Return 

Heart Abnormal to office: 

Rate: (Mark all that apply Respiratory and describe): Rate: 

Abdomen 

Check 

Head/fontanels 

is a federally Lead mandated questionnaire, component risk identified: of the checkup. Y The N 

Additional: Appearance the box if all items 

Mouth/throat 

Nose in the table are within 

Genitalia 

Abdomen normal limits 

Current Parental See new Medications: 

concerns/changes/stressors patient history form in family or home: Temperature: See growth graph 

Skin Teeth Extremities 

(WNL). 

form allows Parental iNtErVal TB space questionnaire*, concerns/changes/stressors for 

hiStorY: 

documenting risk identified: up-to-date in family or Y deferred or N home: Weight: Teeth Eyes Normal Head/fontanels # (Mark here ( if Neurological Mouth/throat all %) items Height: are WNL) Back Genitalia ( %) 

immunizations, Ordered Psychosocial/Behavioral *TB today: skin 

including 

test if indicated 

rationale for deferral. 

PPD placed 

Skin Teeth Extremities 

Visits 

NKDA 

other health-care 

Allergies: Health providers, Issues: facilities: Y N 

Abnormal BMI: Ears (Mark ( all that %) Heart/pulses apply and describe): Rate: Musculoskeletal 

Findings: (See back for forms) 

Blood Audiometric Eyes Screening: Neurological Back 

Appearance Pressure: / Lungs Nose Respiratory Abdomen Hips Rate: 

Each form Psychosocial/Behavioral also includes the age-appropriate Health Issues: vaccine Y N 

R Ears 1000Hz 2000HZ Heart/pulses 4000HZ Musculoskeletal 

Findings: 

Check 

Abnormal Temperature Head/fontanels only the 

findings: (optional): 

box adjacent Mouth/throat 

choices. Check the box for any vaccines given the day of the L 1000Hz 2000HZ Lungs to the body part Genitalia 

Parental 4000HZ Hips with the 


concerns/changes/stressors in family or home: 

Signature/title TB questionnaire*, risk identified: Y N 

Signature/title abnormal Skin 

checkup. DEVELOPMENT: 

Abnormal Normal result (Mark findings: here if Teeth all items are WNL) Extremities 

*TB The skin separate test if indicated immunization PPD record placed also serves as Eyes Neurological Back 

sufficient 

Use TB documentation. 

questionnaire*, of standardized risk tool: identified: Y P N F 

Abnormal Visual Acuity (Mark Screening: all that apply and describe): 

Psychosocial/Behavioral (See back for form) Health Issues: Y N 

Ears Heart/pulses Musculoskeletal 

Findings: *TB Visits ASQ* skin to test other ASQ-SE* if indicated health-care PEDS* providers, PPD Other: placed facilities: 

OD Appearance / OS Nose / OU Lungs 

Lungs 

Hips/ 

*ASQ, DEVELOPMENT: 

(See ASQ-SE, back for PEDS, form) required for use as of 9/1/11 

Additional: Head Mouth/throat GI/abdomen 

Abnormal findings: 

Laboratory 


Teeth HEALTH Skin # EDUCATION/ANTICIPATORY 

Teeth Extremities 

Parental TB DEVELOPMENT: 

questionnaire*, Additional: 

Laboratory ASQ* concerns/changes/stressors risk identified: Y 

services with PEDS* screening for Other in family N or home: 

age-appropriate 

GUIDANCE Eyes (See back Neck for useful topics) Back 

*TB Use NUTRITION*: 

skin of standardized test if indicated tool: P PPD F placed 

Teeth # 

laboratory 

Autism 

tests 

screening 

are a federally 

if not performed 

required component 

at 18 months: 

of the 

P F Subjective Ears Vision Screening: Heart P F Musculoskeletal 

Problems: ASQ* (See back 

MCHAT* Y 

for PEDS* form) 

Other N Other 

Hearing Selected Checklist health for topics Parents: addressed P in F any 

Neurological 

of the 

checkup. Autism Assessment: 

This section screening includes if not performed age-appropriate at 18 months: required P F Subjective 


Vision Screening: *ASQ, Psychosocial/Behavioral PEDS, M-CHAT required Health 

DEVELOPMENT: 

use Issues: as of Y 9/1/11 N 

Abnormal (See back findings: 

Additional: for form) 

laboratory Findings: MCHAT* tests. The form Other allows space for documenting tests Hearing 

• School 

Checklist 

Readiness/Limitations 

for Parents: P F 


Teeth # 

• Nutrition 

*ASQ, PEDS, M-CHAT required for use as of 9/1/11 

(See 

• Personal 

back for 

Hygiene 

form) 

HEALTH EDUCATION/ANTICIPATORY • Safety 

NUTRITION*: 

*See ASQ* Bright Futures PEDS* Nutrition Book Other if needed 

Autism screening if not performed at 18 months: P F Subjective GUIDANCE Vision (See Screening: back for useful P F topics) 

Problems: TB questionnaire*, Y N risk identified: Y N 

HEALTH ASSESSMENT EDUCATION/ANTICIPATORY 

Assessment: 

NUTRITION*: 

IMMUNIZATIONS 

MCHAT* Other 

Hearing Checklist for Parents: P F 

*TB skin test if indicated PPD placed 


*ASQ, Problems: PEDS, Y M-CHAT N required for use as of 9/1/11 

(See Selected back health for form) topics addressed in any of the 

(See back for forms) 

Assessment: Up-to-date 


Selected health topics addressed in any of the 


HEALTH • Communication EDUCATION/ANTICIPATORY 

• Discipline 

NUTRITION*: 

dEVElopMENtal SCrEENiNG: 

following Visual Acuity 

• Development/Behaviors 

areas*: Screening: 

GUIDANCE (See back for useful • Nutrition topics) 

*See Bright Futures Nutrition Book if needed 

Communication 

Discipline 

12/1/2011Problems: Use of standardized Y N tool: P F 

OD / OS / OU / 

– 3 – • Social Interaction 

• Safety 

Assessment: ASQ ASQ:SE PEDS 

Subjective Development/Behaviors 

Hearing Screening: P 

F Nutrition 

IMMUNIZATIONS 

*See Given Bright today: Futures DTaP Nutrition HAV Book if needed HBV HIB IPV Selected health topics addressed in any of the 

• Social Interaction 

• Safety 

4 YEAR VISIT 2 MONTH VISIT CHILD CHILD HEALTH HEALTH RECOR 

T Child CHILD HEALTH hEalth HEALTH CHILD RECORD rECord 

RECORD HEALTH RECORD 

Dental R 

Other R 

Return 

Signatur

s: 

s: 

e: 

e: 

e: 

PV 

l 

-HIB 

nza 

e: 

Abnormal Appearance Skin Visits Lead to (Mark questionnaire, other all health-care that Teeth Nose apply risk and providers, identified: describe): facilities: Genitalia Lungs Y N 

Appearance Eyes Head TB questionnaire*, Neurological Mouth/throat Nose risk identified: Abdomen Extremities GI/abdomen Y N 

Ears Skin Head/fontanels Psychosocial/Behavioral 

*TB skin test if indicated Heart Teeth Mouth/throat Health Issues: 

PPD Back Extremities Genitalia placed 

Y N 

Eyes Skin Findings: Parental (See back concerns/changes/stressors for forms) 

Neurological in Musculoskeletal 

Back Extremities family or home: 

Abnormal Ears Eyes findings: 

Heart/pulses Musculoskeletal 

Back 

Ears Lungs Musculoskeletal 

Document Abnormal DEVELOPMENT: 

Psychosocial/Behavioral Lead all findings: abnormal questionnaire, findings risk Health in identified: the space Issues: Hips below Y the N 

table 

or on Abnormal additional Use Findings: TB 

of 

questionnaire*, findings: standardized paper as needed. risk 

tool: 

identified: Y 

P 

N 

F 

*TB 

ASQ* 

skin test 

ASQ-SE* 

if indicated 

PEDS* 

PPD 

Other: 

placed 

Additional: *ASQ, 

(See 

ASQ-SE, 

back for 

PEDS, 

forms) 

required for use as of 9/1/11 

Teeth Lead # questionnaire, risk identified: Y N 

The form TB contains questionnaire*, space for risk additional identified: documentation. Y N 

Visual Additional: DEVELOPMENT: 

*TB NUTRITION*: 

Acuity skin test Screening: if indicated PPD placed 

OD Breasts Additional: Use 

Problems: (See / of back standardized /5 Y for Genitalia OS forms) N / tool: /5 OU / P F 

Hearing Assessment: 

ASQ* Checklist ASQ-SE* for Parents: PEDS* P P F F Other: 

Document Subjective (See *ASQ, back the ASQ-SE, Hearing Tanner for form) 

PEDS, stages Screening: required on the P for lines F use provided. as of 9/1/11 

Subjective 

MEDICAID 

DEVELOPMENT: 

Vision Screening: P P F F 

*See Bright ID: Futures Nutrition Book if needed 

HEALTH Newborn Use of Hearing EDUCATION/ANTICIPATORY 

standardized Screening: tool: P F 

GUIDANCE HEALTH PRIMARY Completion CARE GIVER: 

NUTRITION*: 

ASQ* 

IMMUNIZATIONS 

EDUCATION/ANTICIPATORY 

date: ASQ-SE* (See back / for PEDS* / useful Results: Other: topics) 

GUIDANCE PHONE: Problems: *ASQ, ASQ-SE, Y (See PEDS, N back required for useful for topics) as of 9/1/11 

Document 

INFORMANT: 

HEALTH Selected Assessment: Up-to-date the EDUCATION/ANTICIPATORY 

health results topics and completion addressed date in any of of the the newborn 

hearing following GUIDANCE Selected test Deferred areas*: in health this -(See section. Reason: topics back Results addressed for useful may in be any topics) accessed of the at 

https://www.provideraccess.tehdi.com following • School NUTRITION*: areas*: Readiness • Nutrition using a current user 

name UNCLOTHED Selected • Development 

and 

School *See Problems: Bright 

password. 

Activity health Futures Y 

If PHYSICAL topics N Nutrition no user 

• addressed Safety Oral Book 

name 

Health EXAM if needed 

or 

in 

password 

any of the 

has yet 

following • Physical Development 

been 

See 

established, Given 

Assessment: areas*: today: Activity 

growth graph 

contact DTaP • Nutrition 

TEHDI HAV at call HBV 512-458-7726 HIB or IPV 

512- 

• Physical Newborn IMMUNIZATIONS 

458-7111 

Meningococcal Activity Care 

• Safety Parental/Maternal 

ext. 2128, or contact 

MMR 

OZ Systems 

Pneumococcal Well-Being 

ASSESSMENT 

at 866-427-5768 

Weight: • Newborn Varicella Transition ( MMR-V •%) Safety Height: HIB-HBV ( DTap-HIB %) 

option 2 *See or email: Bright Futures OzHelp@oz-systems.com Nutrition Book if needed to obtain the 

BMI: ASSESSMENT 

• Nutrional 

Up-to-date 

DPAP-IPV ( Adequacy DTaP-HB-IPV %) Heart Rate: DTaP-IPV-HIB Influenza 

required 

Blood 

login Deferred 

Pressure: 

information. - Reason: 

IMMUNIZATIONS / Respiratory Rate: 

Standardized Temperature: ASSESSMENT 

LABORATORY 

sensory screenings for vision and hearing are 

required Normal Given as Up-to-date part (Mark today: of here the DTaP physical if all items HAV examination, are WNL) HBV including HIB visual IPV 

Up-to-date 

acuity 

Abnormal 

and Meningococcal Deferred 

Deferred 

audiometric 

- Reason: 

(Mark- all Reason: that 

screening MMR 

apply and 

tests 

describe): 

at specific Pneumococcal ages. 

Visual Appearance acuity Varicella and audiometric MMR-V 

Nose screening HIB-HBV tests Lungs performed DTap-HIB 

during PLAN/REFERRALS 

Head the 

DPAP-IPV 

Given checkup today: may 

DTaP-HB-IPV 

DTaP be Mouth/throat documented 

DTaP-IPV-HIB 

HAV HBV on GI/abdomen the HIB lines 

Influenza 

IPV 

provided Skin Ordered Meningococcal or maintained today: as Teeth supplemental MMR documentation Extremities Pneumococcal in 

LABORATORY 

the Dental PLAN/REFERRALS 

medical Eyes Varicella Referral: record. Y MMR-V Neurological HIB-HBV Back DTap-HIB 

Other Ears Referral(s) DPAP-IPV DTaP-HB-IPV Heart DTaP-IPV-HIB Musculoskeletal Influenza 

Documentation PLAN/REFERRALS 

Up-to-date of test results received from a school vision 

Dental 

and Abnormal hearing Signature/title Deferred Referral: - Y Reason: 

LABORATORY 

program findings: or other source may replace the required 

Other Referral(s) 

visual 

Referral(s): 

Return acuity to office: or audiometric screening if conducted within 

the 12 months Ordered Up-to-date prior today: 

the checkup. If testing was completed 

elsewhere, Return Deferred to documentation office: - Reason: of the results including the date 

and the name of the provider who completed the screening 

must be retained in the medical record. 

Additional: 

Return Signature/title to office: 

Ordered today: 

The Breasts actual results /5 must Genitalia be maintained /5 in the record. 


Subjective Hearing Screening: P F 


Subjective Vision Screening: P F 


The HEALTH Hearing Checklist EDUCATION/ANTICIPATORY 

for Parents is available on the back 

of the GUIDANCE checkup form (See for reference back for for useful specific topics) ages as 

an optional tool. Subjective sensory screenings through 

provider 

Selected 

observation 

health 

and/or 

topics addressed 

informant report 

in any 

are 

of the 

documented 


by checking the appropriate box when a visual acuity or 

• School Activity • Oral Health 

audiometric • Development screening test is • not Nutrition required. 

• Physical Activity • Safety 

ASSESSMENT 

12/1/2011 


ISIT CHILD DISCHARGE 7 YEAR 3 HEALTH VISIT RECORD TO 5 DAY VISIT CHILD CHILD HEALTH REC R R 

– 4 – 

Current Additional: Appearance 

Medications: 

Ears Heart Nose Back Lungs 

Teeth Head # 

Mouth/throat Abdomen Musculoskeletal 

Skin Teeth Genitalia 

Visits 

Abnormal 

Audiometric Eyes 

to other 

findings: 

Screening: health-care 

Neurological 

providers, facilities: 

Extremities 

R Ears 1000Hz 2000HZ Heart 4000HZ Back 

L 1000Hz 2000HZ 4000HZ Musculoskeletal 

Parental 

Abnormal 


findings: 

in family or home: 

Additional: 

Health Teeth 

Visual Acuity 

# Education/Anticipatory 

Screening: 

Guidance OD / (See OS back for / useful OU topics) / 

Psychosocial/Behavioral Health Issues: Y N 

Health Findings: 

Audiometric 

HEALTH Education 

Screening: 

EDUCATION/ANTICIPATORY 

Including Anticipatory Guidance is a 

R Additional: 1000Hz 2000HZ 4000HZ 

federally GUIDANCE required component (See back of for the useful checkup. 

L Teeth 1000Hz # 

2000HZ 4000HZ topics) 

Audiometric 

Lead questionnaire, 

Selected health risk identified: Y N 

Visual topics addressed in any of the 

R 

TB 

following 1000Hz 

questionnaire*, 

Acuity Screening: 

risk 

areas*: 2000HZ 

identified: 

4000HZ 

Y N 

*TB 

OD 

L • 1000Hz 

skin test 

/ 

if indicated 

OS / 

School Readiness/Limitations 

2000HZ 

PPD 

OU 

• 4000HZ 

placed 

/ 

Nutrition 

(See back for forms) 

HEALTH • Personal EDUCATION/ANTICIPATORY 

Hygiene 

• Safety 

GUIDANCE Visual Acuity Screening: 

(See back for useful topics) 

General 

OD ASSESSMENT 

categories 

/ 

for 

OS 

useful 

/ 

health education 

OU / 

DEVELOPMENT: 

topics are 

listed Use Selected in of this standardized section, health topics specific tool: addressed age-appropriate in any P of the F topics are 

HEALTH EDUCATION/ANTICIPATORY 

listed following ASQ* on the areas*: back ASQ-SE* of the form. PEDS* Checking Other: 

box indicates that 


health *ASQ, • education School ASQ-SE, Readiness/Limitations 

and PEDS, anticipatory required for guidance use as • of Nutrition 9/1/11 were provided 

• Personal Hygiene 

• Safety 

as required. Selected There health is topics no requirement addressed to in document any of the specific 

subject(s) following covered, areas*: although the provider may choose to do 

NUTRITION*: 

ASSESSMENT 

so 

Problems: 

separately • School 

Y 

from Readiness/Limitations 

N 

the form. If there is a • problem Nutrition requiring an 

action Assessment: PLAN/REFERRALS 

• or Personal outcome, Hygiene documentation may be • Safety made in the space 

provided for “Assessment” and “Plan/Referrals.” 

Dental ASSESSMENT 

Referral: Y 

ASSESSMENT 

*See Other Bright Referral(s) Futures Nutrition Book if needed 

IMMUNIZATIONS 

Plan/Referrals 


Return to office: 

Up-to-date 

Dental Deferred Referral: - Reason: Y 

Other Referral(s) 

Beginning PLAN/REFERRALS 

Given today: 

at 6 months 

DTaP 

of age, 

HAV 

a dental 

HBV 

referral 

HIB 

is a required 

IPV 

component 

Dental Referral: 

of the checkup 

Y 

until a dental home is established 

Return Meningococcal to office: MMR Pneumococcal 

and Signature/title 

Other may Varicella Referral(s) be documented MMR-V here HIB-HBV or with supplemental DTap-HIB 

information DPAP-IPV maintained DTaP-HB-IPV in the medical DTaP-IPV-HIB record. Influenza 

LABORATORY 

Return to office: 

The time 

Up-to-date 

that is recommended for a return appointment may 

be Signature/title Deferred - Reason: 

documented in this section. It does not have to include 

the exact date but may include a time frame for the return 

checkup Ordered or follow-up today: visit. 



The person completing the checkup and the staff assisting 

in completion of the checkup sign on the line with their title 

included. 

4 YEAR 4 YEAR VISIT 4 YEAR VISIT VISIT CHILD CHILD HEALTH CHILD HEALTH REC 

Norm 

Abnorm 

Appe 

Head 

Skin 

Eyes 

Ears 

Abnorm 

Addition 

Teeth 

Audiom 

R 1000 

L 1000 

Visual A 

OD 

HEALT 

GUIDA 

Selec 

followin 

• Sch 

• Per 

ASSE 

PLAN 

Dental R 

Other R 

Return 

Signatur

Back of forms 

The back of each form includes age-appropriate Health 

Education and Anticipatory Guidance and modified versions of 

screening questionnaires. 

Typical Developmentally Appropriate Health Education Topics 

The health topics included in the list for each age group are 

age-specific. No notation is required on the back of the form; 

only the check in the box on the front of the form is required. 

Reference materials may be found at http://brightfutures.aap.org/. 

Hearing Checklist for Parents (optional) 

TB Questionnaire 

LEAD RISK FACTORS 

02/2012 

– 5 –

Texas HealTH sTeps - Fostercare Texas

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