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

(EPSDT) 4 - Year Visit Page 2

Patient Sticker

NAME:

DOB:

MED RECORD #:

DOV: ________

PROCEDURES:

ANTICIPATORY GUIDANCE:

 Hematocrit or Hemoglobin

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

 TB Test

 Cholesterol Screening

Injury/Serious Illness Prevention:

 Blood lead test (is required at this age)

 Booster car seat until 80 lbs  Smoke alarms  No passive smoke

DENTAL REMINDER

(Oklahoma Tobacco Helpline: 1.800.QUIT.NOW)  Sun protection

 Yearly dental referral  Fluoride source?

 Water safety  Bicycle helmet  Playground safety

IMMUNIZATIONS DUE at this visit:

 Other: ____________________________________________

D T a p 5 #______

 Given

 Not Given

 Up to Date

Violence Prevention:

I P V 4 #______

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

 Given

 Not Given

 Up to Date

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

M M R V 2 #______

 Other:

 Given

 Not Given

 Up to Date

Flu (yearly)

Sleep Safety Counseling:

 Given

 Not Given

 Up to Date

 Bedtime Interaction  May not need naps  Managing out of bed

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

behavior with bedtime pass  Read to child (e.g. Reach out and Read)  Limit TV

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

(day and nighttime)

H e p A #______

 Other: ____________________________________________

 Given

 Not Given

 Up to Date

H e p B #______

Nutrition Counseling:

 Given

 Not Given

 Up to Date

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

H i b #______

 Whole grains  Healthy snacks  Vitamins

 Given

 Not Given

 Up to Date

 Other:_____________________________________________

P C V #______

 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; introduce a few clear

 Given

 Not Given

 Up to Date

rules (e.g., 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:

Provider Signature: _____________________________________________ Date: _____________________________________

OHCA Revised 03/13/2014

CH-12

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

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