4 - Year Child Health Supervision (Epsdt) Visit Form

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Patient Sticker
4 - 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: (at least 1 acuity/alignment exam required between 3 and 5 yrs)
Acuity (Allen cards, Snellen chart, or HOTV test) done
Yes
No
Hearing:
Initial/Interval History:
Passed Screen
R i g h t
L e f t
Bilaterally
Failed Screen
R i g h t
L e f t
Bilaterally
Refered for: Audiological evaluations
Conditioned play audiometry or
Acousitic emittance testing (including reflexes) or
OAEs
FSH:
PHYSICAL EXAMINATION (check appropriate box):
FSH form reviewed (check other topics discussed):
Daily care provided by
Daycare
Parent
Other:
COMMENTS
N L AB
N E
Adequate support system?
Yes
No _____________
NL-normal, AB-abnormal, NE-not
examined
Adequate respite?
Yes
No
General
DEVELOPMENTAL/BEHAVIORAL ASSESSMENT:
Skin
Parent Concerns Discussed? (Required)
Yes
Fontanels
Standardized Screen Used? (Optional)
Yes
No
Eyes:
See instrument form:
PEDS
Ages & Stages
Red Reflex,
Appearance
Other: _____________________________________
Ears, TMs
DB Concerns: (e.g. sleep/feeding) ___________________
__________________________________________________
Nose
Lips/Palate
Teeth/Gums
Clinician Observations/History: (Suggested options)
Tongue/Pharynx
Motor Skills
Hops on 1 foot; summersaults; catch bounced ball Y
N
Neck/Nodes
Fine Motor Skills
Chest/Breast
Can use scissors, markers, pencils, clay
Y
N
Lungs
Y
N
Can brush teeth, wash hands, get a drink
Heart
Language/Socioemotional/Cognitive Skills
Y
N
Can follow 3-step command
Abd/Umbilicus
Uses complex sentences; knows age, name, town
Y
N
Genitalia/
Y
N
Has 15-20 minute attention span in a group
Femoral Pulses
Toilet trained (occasional nighttime wetting ok)
Y
N
Y
N
Can dress and undress independently
Extremities,
Y
N
Learning to tie shoes, zippers, and buttons
Clavicles,
Y
N
Hips
Likes to be with other children, able to cooperate
and share well but doesn't always wants to
Muscular
Y
N
Still has confusion between reality and fantasy
Neuromotor
Parent – Infant Interaction
Back/Sacral
Interaction appears age appropriate
Y
N
Dimple
Clinician concerns regarding interaction:
OHCA Revised 03/13/2014
CH-12

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