6 -10 Year Child Health Supervision (Epsdt) Visit Form (Page 2 of 2) in pdf

(EPSDT) 6 -10 Year Visit Page 2

Patient Sticker

NAME:

DOB:

MED RECORD #:

DOV: ________

PROCEDURES:

ANTICIPATORY GUIDANCE:

 TB Test

Select at least one topic in each category (as appropriate to family):

 Cholesterol Screening

 Blood lead test (up to 72 mos)

Injury/Serious Illness Prevention:

 Seat belts  Smoke alarms  No passive smoke (Oklahoma

DENTAL REMINDER

Tobacco Helpline: 1.800.QUIT.NOW)  Sun protection  Water

 Yearly dental referral  Fluoride source?

safety  Bicycle helmet  Playground safety

 Other: ____________________________________________

IMMUNIZATIONS DUE at this visit:

Flu (yearly)

Violence Prevention:

 Given

 Not Given

 Up to Date

 Adequate support system?  Adequate respite?  Feel safe in

D a t e F l u p r e v i o u s l y g i v e n :

neighborhood?  Domestic Violence?  Gun Safety  Stranger safety

 Other:

C a t c h - u p o n v a c c i n e s :

T d # ______

Sleep Counseling/Interaction:

 Given

 Not Given

 Up to Date

 Bedtime Interaction  Managing out of bed behavior with bedtime pass 

I P V #______

Read to child (e.g. Reach out and Read)  Limit TV (day and nighttime)

 Given

 Not Given

 Up to Date

 Other: ____________________________________________

M M R V #______

 Given

 Not Given

 Up to Date

Nutrition Counseling:

H e p A #______

 Begin 2% cow's milk (~16 oz/day)  Limit juice/soft drinks (4 oz or

 Given

 Not Given

 Up to Date

less/day)  Whole grains  Healthy snacks  Vitamins

H e p B #______

 Other: _____________________________________________

 Given

 Not Given

 Up to Date

What to anticipate before next visit:

Vaccines for HIGH-RISK:

 Discipline  Help child learn self-control skills (e.g., not interrupting, not

MPSVA (Meningococcal)

fighting with siblings)  Define unacceptable behavior; provide clear rules (e.g.,

 Given

 Not Given

 Up to Date

washing hands before eating)  Other:

Reason Not Given if due: List Vaccine(s) not given:

 Vaccine not available __________________________

 Child ill

__________________________

 Parent Declined

_________________________

 Other __________ __________________________

ASSESSMENT:  Healthy, no problems

PLAN/RECOMMENDATIONS:  Do vaccines/procedures marked above  Other ____________________________________

 See box above for Anticipatory Guidance Topics discussed at today's visit

Next Health Supervision (EPSDT) Visit Due:

(visits required on even years from 6-12 years)

Provider Signature: _____________________________________________ Date: _____________________________________

OHCA Revised 03/14/2014

CH-14

6 -10 Year Child Health Supervision (Epsdt) Visit Form Page 2

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