Established Patient Screening Form
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1NEVADA HEALTHY KIDS (EPSDT)/WELL BABY/WELL CHILD
Established Patient Screening Form (CPT 99391-99395)
Name_______________________________________ Date__________________DOB________________Age________Sex______
Medicaid #___________________Parent/Guardian Name___________________________Provider NPI____________________
Patient’s Medical History
History reviewed from last visit.
Any changes since last visit?
_____No _____Yes
_____No
___Yes__________________________________
Family Medical: ____
Refer to completed history form in chart. Updates? ____________________________________________________
Growth/Vital Signs
Ht____________ (_____ %)
Temp__________
Pulse__________
Resp__________
B/P__________
Allergies_________________________________
Wt___________ (_____ %)
Current
Medications____________________________________Nutrition______________________________________________
HC or BMI___________ (_____ %)
Present
Concerns_______________________________________________________________________________________
Physical Exam-unclothed
(N- Normal
A- Abnormal
NE- No exam)
N
A
NE
N
A
NE
N
A
NE
____
____
____ Appearance
____
____
____ Nose
____
____
____ Abdomen
____
____
____ Head/Face
____
____
____ Mouth/Teeth
____
____
____ Genitalia
____
____
____ Hair/Scalp
____
____
____ Neck
____
____
____ Musculoskeletal
____
____
____ Eyes/Vision Screen
____
____
____ Heart/Lungs
____
____
____ Extremities
____
____
____ Ears/Hearing Screen
____
____
____ Skin/Nodes
____
____
____ Neuro
Describe any abnormalities: _______________________________________________________________________________________________
Developmental/Emotional Behavior
Age/Culturally appropriate
(i.e. through parental interview, observation or screening tool): _____ Yes
_____ No
Name of screening tool, if used: _____________________________________ Referral: ______________________________________________
Anticipatory Guidance/Nutrition/Safety
(Check each one that is discussed with patient/caregiver.)
_____ Nutrition
_____ Adequate Sleep
_____Limit TV/Computer Time
_____ Maternal/Caregiver Depression
_____ Vitamins
_____ Active Play
_____ Social/School Adjustment
_____ Pool/Water Safety
_____ Brush Teeth/Visit Dentist
_____ No Smoking in House/Car
_____ Privacy/Hygiene
_____ Bike/Helmet Safety
_____ Family Relationships
_____ Car Seat/Safety Belt
_____ Puberty/Sex
Impression
Well Child
Normal Growth/Development
Next visit due ___________
____Yes ____No Dx: ______________
____Yes ____No Dx: _____________
Treatment/Plan/Referral
_____ Fluoride Varnish Application
_____ Refer to dentist
_____Refer to Specialist
Type of Specialist__________________________
Immunizations Given
_____ Up-to-date
_____ DTaP ( DTaP, DTaP-Hib, DTaP-HepB-IPV, DT, Tdap, Td)
_____ MMR( MMR, MMRV)
_____ Hib (Hib, Hib-HepB, DTaP-Hib)
_____ Meningococcal (MCV4, MPSV4)
_____ Hep A
_____ Pneumococcal (PCV, conjugate, PPV, polysaccharide)
_____ Hep B (HepB, Hib-HepB, DTap-HepB-IPV)
_____ Polio (IPV, DTaP-HepB-IPV)
_____ HPV
_____ Rotavirus
_____ Influenza (TIV, LAIV)
_____ Varicella (Var, MMRV)
Laboratory Ordered
_____Up-to-date
_____ Hemoglobin/Hematocrit
_____ Lead Testing
_____ PKU
_____ Sickle Cell
_____ TB Test
_____ U/A
_____ Other________________________________
Provider Signature:
Date: _________________________________
________________________________________________________________
NMO 25C (11/08)
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