MISSOURI DEPARTMENT OF SOCIAL SERVICES ... - …

1 I. INTERVAL HISTORY/PARENT S CONCERNS:Naps:Activity:Child Care:Injuries:*Family High Risk Factors:*Nutrition: Milk: _____ , _____ oz/feeding _____ times per day WIC ReferralNutrition: Solid food (encourage all food groups:Output: Urine: _____ Stools: _____Output:Diaper Rash: _____Chronic Illnesses:ER/Hospital utilization since last visitTriggers reviewed:Medications changed/refilled:EducationConsult/Referr alMISSOURI DEPARTMENT OF SOCIAL SERVICESMO HEALTHNET DIVISIONHEALTHY CHILDREN AND YOUTH SCREENING GUIDE24-35 MONTHSMO 886-3996 (10-07)II. UNCLOTHED PHYSICAL EXAM: Check Growth ChartGeneralSkinHeadEyesEarsNoseOrophary nxNeckLungsHeartPulsesAbdomenBackGUSkele talNeuroSYSTEMNLCOMMENTSABNNESIGNATUREDA TEDATENAMEDATE OF BIRTHMO HEALTHNET NUMBERMEDICAL RECORD NUMBERTEMPRRHEIGHTBMIALLERGIES%NKDAPULSE HEAD CIRCWEIGHTMEDICATIONS%%NONECOMMENTSE merging SkillsImitates adults2 step commandsAsks for specific foodTells first and last nameUses pronouns 50 words2-word phrasesUnbuttons clothesToilet trainingAttentive 2 minutesImmunizations given today:UTD Written information given Consent signed (Follow the recommended immunization schedule approved by the ACIP, AAP, and AAFP)FULL SCREEN (I-X)WITH REFERRALPARTIAL SCREEN (I-V)WITH REFERRALDEVELOPMENTAL & MH SCREENWITH REFERRALHEARING SCREENWITH REFERRALVISION SCREENWITH REFERRALDENTAL SCREENWITH REFERRALIII.)

2 ANTICIPATORY GUIDANCE (Check all that apply)IV: LAB/IMMUNIZATIONS: Labs: Blood lead level (if not done previously at 24 months) Hct (if high risk) UA (if high risk)V. LEAD SCREEN Lead Assessment Guide completeNegative screenPositive screen - draw blood lead levelVI. DEVELOPMENTAL AND MENTAL HEALTH: Parents As Teachers referral(Check all that apply)VII. FINE MOTOR/GROSS MOTOR: (Check all that apply)X. DENTALD ental referral for complete diagnostic work-upTeeth brushing by parentsNormal tooth eruption timesAssess teeth development and oral hygiene - Teeth cleaningFluoride supplements if water fluoridation less that ppmSharing with othersPeer play is parallelTantrums*Autonomy/ChoicesDiscipl ine/Time out*Matches, lightersTelevision/ExerciseReading to childParental smokingMinimal SkillsHelps in house - RSix words - RRemoves garments - RPlays with otherThree words - RchildrenUses spoon, fork - RAppropriate emotionalPoints to 2 picturesexpressionVIII.

3 HEARING: (Check all that apply)Parental perception of hearingEar exam with pneumatic otoscopeObservational screening with noisemakerERA/ABR screen for infant in tertiary care > 5 daysFamily history of hearing disordersPMHx: NICU admission/ ear infection/ head injury/congenital anomalies/ meningitis/ mumps/ cerebral palsyTympanometryIdentifies familiar picturesNames desired objects (candy, juice)IX. VISION: (Check all that apply)Parental perception of visionObservation forblinkingCover testpupillary responseHandles spoon wellred reflex/fundusScribbles on papertrackingocular movementsEnjoys short books, bright picturesFamily history of visual disordersAttempts to pick up small objects, bits of foodPMHx:NICU admission/prolonged oxygen administrationOutdoor hazardsWater safety/poolsBalloon/plastic bag safetyHot/ColdWater heater temperature (< 130 F)Bathtub safetyToddler car seats/AirbagsIngestions/IpecacSmoke detectorMinimal SkillsWalks up steps - RStacks 2-4 cubesRunsKicks ball forwardDumps raisins from bottle - demonstrateEmerging SkillsStacks 5-6 blocksCircular strokesClimbs up/down stairsJumps wellImitates horizontal & vertical lineSquats and recovers wellCOMMENTSCOMMENTSORDERSASSESSMENT/EDU CATION/PLANSIGNATUREDATEN ursery SchoolToilet training readinessMasturbationFeeding:3meals with snacksVariety of foodPica*Self feedingPoor appetite*COMMENTSCOMMENTSCOMMENTSMO 886-3996 (10-07)NOTE.

4 It is recommended that assessment preventive dental servicesand oral treatments for children begin at age 6-12 months and berepeated every 6 months or as medically