6 - Month Child Health Supervision (Epsdt) Visit Form
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1
2Patient Sticker
6 - Month 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:
Follows objects and eyes team together:
Yes
No
Maternal & Birth History:
Birth HX form reviewed
Hearing:
Initial/Interval History:
Responds to sounds:
Yes
No
PHYSICAL EXAMINATION (check box):
COMMENTS
FSH:
FSH form reviewed (check other topics discussed):
N L AB
N E
NL-normal, AB-abnormal, NE-not
Daily care provided by
Daycare
Parent
examined
Other:
General
Adequate support system?
Yes
No _____________
Adequate respite?
Yes
No
Skin
Fontanels
DEVELOPMENTAL/BEHAVIORAL ASSESSMENT:
Eyes:
Parent Concerns Discussed? (Required)
Yes
Red Reflex,
Appearance
Standardized Screen Used? (Optional)
Yes
No
Ears, TMs
See instrument form:
PEDS
Ages & Stages
Other: __________
Nose
DB Concerns: (e.g. crying/colic) ____________________
Lips/Palate
__________________________________________________
Teeth/Gums
Tongue/Pharynx
Clinician Observations/History: (Suggested options)
Neck/Nodes
Motor Skills (observe head, trunk, and limb control)
Chest/Breast
Visually tracks objects beyond midline
Y
N
Moves arms and legs equally
Y
N
Lungs
Rolls over both ways
Y
N
Heart
Y
N
ATNR (fencer position) gone
Abd/Umbilicus
Y
N
Sits alone
Genitalia/
Fine Motor Skills
Femoral Pulses
Reaches for and rakes at objects
Y
N
Transfers objects hand to hand (by 5 mos)
Y
N
Extremities,
Regards small wad of paper
Clavicles,
Language/Socioemotional Skills
Hips
Y
N
Babbles (vowel-consonant)
Muscular
Raspberry noises (by 5 mos)
Y
N
Neuromotor
Says ah-goo (by 5 mos)
Y
N
Parent – Infant Interaction
Back/Sacral
Y
N
Dimple
Interaction appears age appropriate
Clinician concerns regarding interaction:
OHCA Revised 03/13/2014
CH-5
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