Transcription of CHILD HEALTH RECORD - onlineordersff.com
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CHILD HEALTH RECORD - onlineordersff.com
MEDICAID ID:PRIMARY CARE GIVER:PHONE:INFORMANT:6 MONTH CHECKUP CHILD HEALTH RECORDHISTORY See new patient history formINTERVAL HISTORY: NKDA Allergies: Current Medications: Visits to other HEALTH -care providers, facilities: Parental concerns/changes/stressors in family or home: Psychosocial/Behavioral HEALTH Issues, including Post-partum Depression Screening (use of validated tool required): EPDS PPDS PHQ-9 Other P F Findings: DEVELOPMENTAL SURVEILLANCE Gross and fine motor development Communication skills/language development Self-help/care skills Social, emotional development Cognitive development Mental healthNUTRITION*: Breastmilk Min per feeding: Number of feedings in last 24 hrs: Formula (type) Oz per feeding: Number of feedings in last 24 hrs: Water source: Fluoride: Y N Solids *See Bright Futures Nutrition Book if neededIMMUNIZATIONS Up to date Deferred Reason (if deferred):Given today: DTaP Hep B Hib IPV PCV Hib-Hep B Rotavirus DTaP-IPV-Hep B DTaP-IPV/Hib InfluenzaLABORATORYT ests ordered today:UNCLOTHED PHYSICAL EXAM See growth graphWeight.
Perform a blood lead test if parent/caretaker answers “Yes/Don’t Know” to any of the questions below. Yes Don’t : know No • Child lives in or visits a home, day …
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