Child Health Check-up Tracking Form - Freedom Health

4 to 6 Month <strong>Child</strong> <strong>Health</strong> <strong>Check</strong>-Up <strong>Tracking</strong> <strong>Form</strong>PLEASE PRINTPERSONAL Periodic Interperiodic Parent/Caregiver RequestNAME (Last) (First) ID DATE OF BIRTHDATE AGE ACCOMPANIED BY RELATIONSHIPINTERVAL HISTORYPAST MEDICAL HISTORY WNL ❒DEVELOPMENTAL HISTORY WNL ❒BEHAVIORAL HEALTH STATUS WNLYES ❒ NO (IF NO, DESCRIBE)YES ❒ NO (IF NO, DESCRIBE)❒ YES ❒ NO (IF NO, DESCRIBE)NUTRITIONAL ASSESSMENT❒ BREAST ❒ FORMULA: WIC ❒ YES ❒ NO ❒ REFERRED ❒ VITAMINS ❒ IRON ❒ SOLIDSPHYSICAL EXAMHEIGHT WEIGHT HEAD CIRCUMFERENCEAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.Hip Abduc.ExtremitiesSpineNeuroOtherLAB TESTS❒ LEAD SCREEN (blood @ 12 & 24 mo, @ 36-72 mo. if notpreviously screened; verbal @ 6 mo-6 yrs)SENSORY SCREENNORMAL VISION? (red reflex, cover-❒ OTHER (specify, as indicated)NORMAL HEARING? (i.e.,uncover test, follows)❒ YES ❒ NO ❒ REFERRED responds to sound, repeats sounds)❒ YES ❒ NO ❒ REFERREDDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE? (prone–i.e., rolls over, reaches forobjects, laughs, squeals)❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ CUP, FINGER FOODS ❒ NO BOTTLE IN BED ❒ TEETHING❒ POOL & TUB SAFETY ❒ POISONS ❒ OTHERDIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003

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6 to 12 Month <strong>Child</strong> <strong>Health</strong> <strong>Check</strong>-Up <strong>Tracking</strong> <strong>Form</strong>PLEASE PRINTPERSONAL Periodic Interperiodic Parent/Caregiver RequestNAME (Last) (First) ID DATE OF BIRTHDATE AGE ACCOMPANIED BY RELATIONSHIPINTERVAL HISTORYPAST MEDICAL HISTORY WNL ❒ YES ❒ NO (IF NO, DESCRIBE)DEVELOPMENTAL HISTORY WNL ❒ YES ❒ NO (IF NO, DESCRIBE)BEHAVIORAL HEALTH STATUS WNL ❒ YES ❒ NO (IF NO, DESCRIBE)NUTRITIONAL ASSESSMENT❒ BREAST ❒ FORMULA: WIC ❒ YES ❒ NO ❒ ❒ VITAM INSREFERREDSOLIDSPHYSICAL EXAMHEIGHT WEIGHT HEAD CIRCUMFERENCEAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.Hip Abduc.ExtremitiesSpineNeuroOtherLAB TESTS❒ Hgb/Hct ______ (9 mo, adolescent females & as indicated)SENSORY SCREENNORMAL VISION? (red reflex,follows)❒ LEAD SCREEN (blood @ 12 & 24 mo, @ 36-72 mo. if notpreviously screened; verbal @ 6 mo-6 yrs)❒NORMAL HEARING? (by 9 mo. Turns when called, listens to peopleIRON ❒ F LUORIDE ❒❒ OTHER (specify, as indicated)❒ YES ❒ NO ❒ REFERRED talking, enjoys imitating sounds; by 12 mo. Responds to “no”, follows simple ❒ YES ❒ NO ❒ REFERRE DDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE? (by 9 mo. Plays peek-a-boo, gets tositting, pulls self to stand, thumb-finger grasp, bangs two toys together; by 12 mo. Play pat-a-cake, neat pincergrasp, stands momentarily, walks holding on, points) ❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ BABY-PROOF HOME, POOL ❒ SELF-FEEDING ❒ TALK TO CHILD❒ TALK TO & NAME OBJECTS ❒ SLEEPING ❒ DISCIPLINE,PRAISE❒ SHOES-PROTECT, NOT SUPPORT❒ SUN PROTECTION ❒ OTHER❒ DENTAL HYGIENEcommands, gives objects <strong>up</strong>on request, 1-3 words)DIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003

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18 Month to 3 Year <strong>Child</strong> <strong>Health</strong> <strong>Check</strong>-Up <strong>Tracking</strong> <strong>Form</strong>PLEASE PRINTPERSONAL Periodic Interperiodic Parent/Caregiver RequestNAME (Last) (First) ID DATE OF BIRTHDATE AGE ACCOMPANIED BY RELATIONSHIPINTERVAL HISTORYPAST MEDICAL HISTORY WNL ❒ YES ❒ NO (IF NO, DESCRIBE)DEVELOPMENTAL HISTORY WNL ❒ YES ❒ NO (IF NO, DESCRIBE)BEHAVIORAL HEALTH STATUS WNL ❒ YES ❒ NO (IF NO, DESCRIBE)NUTRITIONAL ASSESSMENTWNL ❒ YES ❒ NO (IF NO, DESCRIBE) WIC ❒ Yes ❒ No ❒Referred❒ FLUORIDEPHYSICAL EXAMHEIGHT WEIGHT HEAD CIRCUMFERENCE❒ REFERREDAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.ExtremitiesSpineNeuroOther❒ DENTAL REFERRAL AGE 3 AND UP REQUIREDLAB TESTS❒ LEAD SCREEN (blood @ 12 & 24 mo, @ 36-72 mo. if not previouslyscreened; verbal @ 6 mo-6 yrs)SENSORY SCREENNORMAL VISION? (eyes straight?, red❒ OTHER (specify, as indicated)reflex, fixation test, cover-uncover test)❒ YES ❒ NO ❒ REFERREDDOES PARENT FEEL SPEECH & HEARING ARE NORMAL FOR AGE? ❒ YES ❒ NODEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE? (by 18 mo. Uses spoon, kicks/throws ball, walksalone; by 3 years jumps in place; knows name, age, and sex; copies a circle)❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ DECREASED APPETITE ❒ READ TO CHILD ❒ TOILET TRAINING❒ TEETH BRUSHING ❒ CONTROL TV VIEWING ❒ SAFETY-CARS &POOL ❒ SUN PROTECTION ❒ OTHERNORMAL HEARING? (2 yr. Uses some understandable speech,combines 2 words, names objects; 3 yr. Uses 3-4 word sentences)❒ YES ❒ NO ❒ REFERREDDIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003

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13 to 21 Year <strong>Child</strong> <strong>Health</strong> <strong>Check</strong>-Up <strong>Tracking</strong> <strong>Form</strong>PLEASE PRINTPERSONAL Periodic Interperiodic Parent/Caregiver RequestNAME (Last) (First) ID DATE OF BIRTHDATE AGE ACCOMPANIED BY RELATIONSHIPINTERVAL HISTORYPAST MEDICAL HISTORY WNL ❒ YES ❒ NO (IF NO, DESCRIBE)DEVELOPMENTAL HISTORY WNL ❒ YES ❒ NO (IF NO, DESCRIBE)BEHAVIORAL HEALTH STATUS WNL ❒ YES ❒ NO (IF NO, DESCRIBE)NUTRITIONAL ASSESSMENTWNL ❒ YES ❒ NO (IF NO, DESCRIBE) ❒ FLUORIDE ❒ REFERREDPHYSICAL EXAMHEIGHT WEIGHT BLOOD PRESSUREAre the following normal?YES NO COMMENTSAppearanceSkinHeadEyesEarsNoseMouth/Throat/Teeth/GumsNodesHeartLungsAbdomenFem. PulseExt. Gen.ExtremitiesSpineNeuroOther❒ DENTAL REFERRAL AGE 3 AND UP REQUIREDTanner Staging:LAB TESTS❒ Hgb/Hct ______ (9 mo, adolescent females & as indicated)SENSORY SCREENNORMAL ❒ YES ❒ NO RESULTS: NORMALVISION? ❒ REFERRED RIGHT _____ LEFT _____ BOTH _____ HEARING?❒ OTHER (specify, as indicated)❒ NORMAL ❒ ABNORMAL (RIGHT _____ LEFT _____) ❒ REFERREDDEVELOPMENT ASSESSMENTIS DEVELOPMENT NORMAL FOR AGE AND CULTURE?❒ YES ❒ NO ❒ REFERREDIMMUNIZATIONS❒ CURRENT ❒ DEFERRED ❒ PROVIDED: LISTHEALTH EDUCATION, ANTICIPATORY GUIDANCE❒ CAR/SEAT BELT SAFETY ❒ SEXUAL ED & STDs ❒ PHYSICAL ACTIVITY❒ PREGNANCY PREVENTION ❒ NUTRITION ❒ COMM. AFFECTION❒ MOTORCYCLE/ HELMET SAFETY❒ SCHOOL PERFORMANCE❒ SMOKING, ALCOHOL, DRUGS❒ BREAST OR TESTICULAR SELF-EXAMDIAGNOSIS:PLAN:SIGNATURE:FPS, FAFH, FMA, FOMA, AHCA-2003