Arkansas Better Chance Program Well Child Screening (Epsdt) Form printable pdf download

Arkansas Department of Human Services

Division of Child Care and Early Childhood Education

ARKANSAS BETTER CHANCE PROGRAM

WELL CHILD SCREENING (EPSDT) FORM

To Parent or Guardian:

In order to provide the best learning experience for your child, teacher must understand your child’s health needs.

State regulations require any child enrolled in the Arkansas Better Chance Pre-K program to have a well child

check-up. In addition, the child must be current on all required immunizations. Please complete this page of the

form, sign it and give it to your child’s physician or licensed nurse practitioner. Once form is completed and

signed on both sides, return the form to your Pre-K program.

Child’s Name (Last, First, Middle)

Child’s Date of Birth

Sex

Parent/Guardian Name

Address, City and Zip Code

Name of Pre-K Program Where Enrolled

Pre-K Program Phone Number

Type of Health Insurance

AR Kids A

Private Insurance

AR Kids B

Other:

Part I – To be completed by parent or guardian before well child screening.

Check answers to the following questions. Explain any “yes” answers in the space provided.

Yes

Do you have any concerns about your child’s general health?

Has your child been diagnosed with any chronic disease (such as asthma or diabetes)?

Does your child have any allergies (like to food, medicine, dust)?

Does your child take any medications (daily or occasionally)?

Does your child have any problems with vision, hearing or speech?

Has your child had any hospitalization, operation, major illness or injury?

In the past 12 months, has your child experienced any difficulty with wheezing or night coughing?

In the past 12 months, has your child experienced excessive weight loss or weight gain?

Has your child had a dental examination in the last 12 months?

10.

Would you like to discuss anything about your child’s health with the health care provider?

If you answered “yes” to any question, please explain below. For illnesses or injuries, include your child’s age at the time.

Question #

Explanation

Parent/Guardian Permission and Release:

I give my permission for the information on this form to be used in meeting my child’s health and educational needs while

enrolled in the Arkansas Better Chance program.

_____________________________________________

______________________________

Signature of Parent/Guardian

Date

Arkansas Better Chance Program Well Child Screening (Epsdt) Form

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