18 Month Form (Healthcheck Program Preventive Health Screen) - West Virginia Department Of Health And Human Resources Early And Periodic Screening, Diagnosis, And Treatment (Epsdt)
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1West Virginia Department of Health and Human Resources
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
18 Month Form
HealthCheck Program Preventive Health Screen
Name___________________________________DOB________________Age__________Sex: M F Wt________Ht________HC________Temp________Pulse___________Screen Date________________
Allergies: □ NKDA ___________________________________________________________ Current Meds: □ None ________________________________________________________________________
Accompanied by: □ Parent □ Grandparent □ Foster parent/organization □ Other _____________________________________________________________________________________________
History: □ No change
□ Developmental Surveillance & Screening:
Health Education/Anticipatory Guidance:
Concerns and questions:
Standardized Screening Tool:
□ Discussed
□ Handout(s) given
□ ASQ3
Other:___________________________________
Healthy and safe habits: nutrition, sleep, oral/dental care,
Follow up on previous concerns:
Results in chart/record □ Yes □ No
injury and violence prevention, social competence, family
relationships, and community interaction
Recent injuries, illnesses, or visits to other providers:
Other:
□ Autism Screening:
Autism Specific Screening Tool:
Social/Family History: Check those that apply
□ No change
□ M-CHAT
Other:_________________________________
Assessment: □ Well Child
□ Other diagnosis
□ Family situation change
Results in chart/record □ Yes □ No
□ Risk indicators reviewed/screen complete
Comments:
Caretaker(s) working outside home? □ Yes □ No
Child care? □ No □ Yes ________________________________
Plan/Referrals:
Other changes since last visit:
For treatment plans requiring authorization, please complete
page 2 on the reverse.
Gets along with other family members □ Yes □ No
Current Health Indicators: Check those that apply
Appropriate Behavior □ Yes □ No
□ No change
Changes since last visit:
Immunizations: □ UTD □ Given, see vaccine record
Do you think your child sees OK? □ Yes □ No
Labs: □ Blood lead, if high risk
Do you think your child hears OK? □ Yes □ No
□ GROWTH PLOTTED ON GROWTH CHART
□ Normal elimination
□ Normal sleep patterns
Referrals: □ Developmental □ Dentist
Comments:
□ Blood lead > 10 ug/dl
Oral Health Screen
□ BTT □ CSHCN
1-800-642-9704
Nutrition: □ Breast feeding; Frequency ___________________
Date of last dental visit______________________________
□ Other referral(s)
Water source:
□ Bottle feeding; Amount_________ Frequency_____________
□ Public
□ Formula ____________________________________________
□ Milk □ Juice □ Water □ Normal eating habits
□ Well □ Tested
□ Vitamins____________________________________________
Fluoride □ Yes □ No
Comments:
□ Current oral health problems:
Follow Up/Next Visit: □ 24 months of age □ Other
□ Passive Smoking Risk: □ Yes □ No
Physical Examination: = Normal limits
_______________________________________________________
Check those that apply
□ General Appearance
□ Skin
Please print Name of Facility or Clinician
Hemoglobin/Hematocrit Risk: □ Low risk □ High risk
□ Neurological
□ Reflexes
□ Head
□ Fontanelles
□ Neck
See Periodicity Schedule for risk indicators
_______________________________________________________
□ Eyes
□ Red Reflex
□ Ocular Alignment
Signature of Clinician/Title
Tuberculosis Risk: □ Low risk
□ High risk
□ Ears
□ Nose
□ Oral Cavity/Throat
□
□ Lungs
□ Heart
□ Pulses
Increased risk of exposure d/t Contacts/Travel/Immigration
□ Abdomen
□ Genitalia
□
Radiographic or clinical findings suggestive of TB
□ Back
□ Extremities
□ Hips
Lead Risk:
□ Low risk
□ High risk
□ Lives in or regularly visits a house/child care facility
Abnormal Findings and Comments:
built before 1970 or that has been recently remodeled?
Possible Signs of Abuse □ Yes □ No
□ Lives near a heavily traveled highway or battery
recycling plant or lives with an adult whose job or hobby
involves exposure to lead?
□ Has a sibling or playmate who has or did have lead
poisoning?
WVDHHR/BPH/OMCFH/HC 10-2014
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