Medical/dental/vision/hearing/medication Review Exam Form printable pdf download

. I

ATTACH IMMUNIZATION RECORD FROM COMPLETED VISIT

NFORMATION MAY BE FILLED OUT BY

. P

AREGIVER OR

ASE

ANAGER IF

EALTH CARE PROVIDER IS UNABLE TO COMPLETE

ROVIDER

MUST SIGN IN PROVIDER INFORMATION SECTION

Medical/Dental/Vision/Hearing/Medication Review Exam Form

Child: ______________________________________

D.O.B: ____________________________________

PID #: ______________________________________

Exam Date: ________________________________

Caregiver/CM: _______________________________

Phone: ____________________________________

Address: ____________________________________

City/State/Zip: _____________________________

Emergency Room Visit:  Yes  No

Child Refused Exam:  Yes  No

 Initial Exam

 Annual

 Illness

 Follow-up

 Injury/Accident

Medical:

 N/A

Type of Illness/Injury: _________________________________________________

Injury/Accident:

Date: ________________

Time of Incident: _______________

Texas Health Steps Well Check Exam (Circle):

5 Days Old

2 Weeks

2 Months

4 Months

6 Months

9 Months

12 Months

15 Months

18 Months

24 Months

30 Months

3 Years Old

Primary Medical Needs (Exam within 7 days before or 3 days after date of placement):  Yes  No

Current Medications: _________________________________

Reason: ________________________

Current Medications: _________________________________

Reason: ________________________

Current Medications: _________________________________

Reason: ________________________

Height: ___________

Weight: _____________

BMI: ______________

Temperature: _________

Pulse: ___________

Blood Pressure: _____________

Respiration: ______________

Head Circumference: ______________

Evidence of Abuse/Neglect:  Yes  No

Evidence of Delay:  Yes  No

Lead Test:  Yes  No

Neurological:  Done

 Not Done

 Abnormal

Autism Screen:  Yes  No

Hemoglobin:  Yes  No

Other Test /Immunization: ____________________________________________________

TB Test: Administered Date: ____________

Read Date: ________________

 Normal

 Abnormal

 Not Done

 Subjective

Vision Test:

Eye Exam:

Right: 20/_________

Left: 20/________

Hearing Screen:  Normal

 Abnormal

 Not Done

 Subjective

Right:  500  1000  2000  4000

Left:  500  1000  2000  4000

 None

 ECI

 Physical

 Occupational

 Speech

Referrals:

Specialist: _________________________________________________

Medical/dental/vision/hearing/medication Review Exam Form

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