6 -10 Year Child Health Supervision (Epsdt) Visit Form
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1
2Patient Sticker
6 -10 Year Child Health
Supervision (EPSDT) Visit
NAME:
DOB:
DOV:
AGE:
SEX:
MED REC#: _______
Pulse:
Meds:
HT: ____________ (______%)
Temp:
WT:
(______%)
Pulse Ox-Optional:
HC:
(______%)
Resp:
Allergies:
NKDA
Reaction:
HISTORY:
SENSORY SCREENING:
Parent Concerns:
Any parent concerns about vision or hearing?
Yes
No
Vision: (optional)
Acuity (Allen cards, Snellen chart, or HOTV test) done
Yes
No
Hearing:
Passed Screen
R i g h t
L e f t
Bilaterally
Initial/Interval History:
Failed Screen
R i g h t
L e f t
Bilaterally
Referred for: Audiological evaluations
Conditioned play audiometry
Acoustic emittance testing (including reflexes) or
OAEs
FSH:
FSH form reviewed (check other topics discussed):
PHYSICAL EXAMINATION (check appropriate box):
Daily care provided by
Daycare
Parent
Other:
COMMENTS
Adequate support system?
Yes
No _____________
N L AB
N E
NL-normal, AB-abnormal, NE-not
Adequate respite?
Yes
No
examined
General
DEVELOPMENTAL/BEHAVIORAL ASSESSMENT:
Parent Concerns Discussed? (Required)
Yes
Skin
Standardized Screen Used? (Optional)
Yes
No
Fontanels
See instrument form:
PEDS
Vanderbilt ADHD
Eyes:
Red Reflex,
Other: _____________________________________
Appearance
DB Concerns: (e.g. behavior/sleep/school) _____________
Ears, TMs
__________________________________________________
Nose
Lips/Palate
Clinician Observations/History: (Suggested options)
Teeth/Gums
Motor Skills
Tongue/Pharynx
Rides a bike well
Y
N
Concerns about coordination
Y
N
Neck/Nodes
Fine Motor Skills
Chest/Breast
Y
N
Any handwriting struggles at school
Lungs
Language/Socioemotional/Cognitive Skills
Heart
Child is learning to read or can read-no problems
Y
N
School is going well
Y
N
Abd/Umbilicus
Has age-appropriate attention span
Y
N
Genitalia/
Likes to be with other children, able to cooperate
Y
N
Femoral Pulses
and share well but doesn't always wants to
Extremities,
Has best friend(s)
Y
N
Clavicles,
Extracurricular activities
Y
N
Hips
Parent – Infant Interaction
Muscular
Interaction appears age appropriate
Y
N
Neuromotor
Clinician concerns regarding interaction:
Back/Sacral
Dimple
OHCA Revised 03/14/2014
CH-14
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