Medicare Benefits Schedule (Mbs) Healthy Kids Check

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Medicare Benefits Schedule (MBS)
Healthy Kids Check
CHECKLIST
Use of a specific form to record the results of the health assessment is not mandatory but the health assessment should
cover the matters listed in the explanatory notes at
Patient’s Name ……………………………………………..…..
Male
Female
DOB:
….../….../…..
Age: …..years …....months
Current contact details
Address ………………………………………………..……….
Phone …………………………………………………..………
….……………………..…………………...…………..…….…..
Parent/Guardian name/s
Healthy Kids Check
Explanation of Healthy Kids Check given
Yes
Consent for Check given
Yes
Date consent was given:
…../…../….
…………………………………………………………..……..….
Signature of Parent/Guardian authorising consent for the
Healthy Kids Check to be undertaken
(the Guide)
Get Set 4 Life – habits for healthy kids
Parent/Guardian advised of the Guide
Yes
Date advised:
…../…../….
………………………………………..……………………..…….
Signature of Parent/Guardian
advised of Get Set 4 Life
Four year old Immunisation
Consent for immunisation given
Yes
Date consent was given:
…../…../….
…………..…………………………..……………………..…….
Signature of Parent/Guardian
If immunisation has previously been given note evidence:
authorising consent for immunisation
Personal Health Record
Yes
Other ……………………………………...…………………….
Vaccine
Batch No.
Date given
Signature / Stamp
Diphtheria, tetanus, pertussis
Poliomyelitis
Measles, mumps, rubella*
*to be given only if MMRV was not given at 18 months

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