Texas HealTH sTeps - Fostercare Texas

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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 See new patient history form 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: Psychosocial/Behavioral concerns/changes/stressors 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 – See new patient history form 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 Current Medications: 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, Psychosocial/Behavioral 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 Psychosocial/Behavioral 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 Deferred - Reason: 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) Signature/title Selected health topics addressed in any of the NUTRITION*: Lead questionnaire, risk identified: Y N Additional: following areas*: 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 GUIDANCE (See back for useful topics) 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: See new patient history form • 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 Current Medications: 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 Use of standardized tool: P F 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 following areas*: 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 Use of standardized tool: 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 GUIDANCE (See back for useful topics) *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 following areas*: Selected health topics addressed in any of the Deferred - Reason: 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
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