Transcription of YEAR CHECKUP - onlineordersff.com
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YEAR CHECKUP - onlineordersff.com
MEDICAID ID:PRIMARY CARE GIVER:PHONE:INFORMANT:3 YEAR 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: Y N Findings: Lead questionnaire, risk identified: Y N TB questionnaire*, risk identified: Y N *Tuberculin skin test if indicated TST(TB questionnaire-Page 2) Use of standardized tool: P F ASQ ASQ:SE PEDS NUTRITION*: Problems: Y N Assessment:*See Bright Futures Nutrition Book if neededIMMUNIZATIONS Up-to-date Deferred - Reason: Given today: DTaP HAV HBV HIB IPV Meningococcal MMR Pneumococcal Varicella MMR-V HIB-HBV DTaP-HIB DTaP-HB-IPV DTaP-IPV-HIB Influenza LABORATORY Up-to-date Deferred - Reason:Ordered today:UNCLOTHED PHYSICAL EXAM See growth graphW
MEDICAID ID: PRIMARY CARE GIVER: PHONE: INFORMANT: 3 YEAR CHECKUP HISTORY CHILD HEALTH RECORD See new patient history form INTERVAL HISTORY: NKDA Allergies: Current Medications:
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