Arkansas Better Chance Program Well Child Screening (Epsdt) Form (Page 2 of 2) in pdf

Child’s Name (Last, First, Middle)

Child’s Date of Birth

Sex

Parent/Guardian Name

To Health Care Professional:

This child is enrolled in the Arkansas Better Chance Pre-K program. State regulations require a comprehensive well child

screening for all enrolled children. The Division of Child Care and Early Childhood Education recommends an Early Periodic

Screening and Diagnostic Treatment (EPSDT) which is age-appropriate. For children enrolled in AR Kids, the cost of the

EPSDT may be billed to AR Kids A or B using the procedure codes below:

AR KIDS A

AR KIDS B

Patient Type

1-4 years

5-11 years

1-4 years

5-11 years

New

99382 EP U1

99383 EP U1

99382

99383

Established

99382 EP U2

99383 EP U2

99382

99383

Part II – To be completed by Health Care Provider. Complete all sections and sign at the bottom.

Weight

Height

BMI

Temp

Blood Pressure

lb.

%ile

in.

%ile

History Update

Yes

Any changes in patient health since last visit? Explain:__________________________________________

Yes

Any family history of heart disease for anyone under 55 years of age?

Yes

Any family history of abnormal cholesterol?

PHYSICAL EXAM

Health

Good appetite

Picky or variable eater

Norm

Abnormal

General

Drinks lowfat milk

Brushes teeth, sees dentist

Head

Encourage diet of fruit and vegetables

Neck

Limits fast food

Eyes

Ears

Social and Behavioral

Nose

Parents discipline appropriately

Praised for good behavior

Throat

Dresses self, helps at home

Has friends and playmates

Mouth

TV and video games are limited

Teeth

Lungs

Screening and Laboratory Results

Heart

Femoral

Test

Result

Date

Comments if abnormal

Pulses

Vision

L_________________

Genitals

Test type:

R_________________

Extremities

Hearing

Gait

Test type:

Spine

Skin

Risk: Yes / No

Neuro

Hemoglobin

Risk: Yes / No

Cholesterol

mg/dL

Risk: Yes / No

Immunizations

Yes

All immunizations are current.

Yes

Child has had all immunizations possible at this time.

Child needs:

DTaP

IPV

HepB

HiB

MMR

Varivax

PCV-7 at ______years/_______ months

Referrals

Follow up visit needed in ______________ weeks / months

CLINIC INFORMATION (or stamp)

Return check at ________ years _________ months

Needs to see dentist. Referral to be made by physician or nurse practitioner.

Name______________________________

Address____________________________

Impressions

City________________________________

Well child, normal growth and development

Zip Code______ Phone________________

_____________________________________________________________

_________________________________________________, MD / DO / NP

Date_____________________________________________

Arkansas Better Chance Program Well Child Screening (Epsdt) Form Page 2

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