Ahcccs Epsdt Tracking Form - 18-21 Years Old - Arizona Health Care Cost Containment System Page 2
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218-21 Years Old
AHCCCS EPSDT Tracking Form
Date
Last Name
First Name
AHCCCS ID #
DOB
Age
Primary Care Provider
PCP ph. #
Health Plan
Accompanied By (Name)
Relationship
Current Medications/Vitamins/Herbal Supplements:
Blood Pressure:
Temp:
Pulse:
Resp:
Allergies:
Weight:
Height:
BMI
2
lb / kg
%
cm
%
kg/m
%
Vision Chart Exam:
Right
Left
Both
Corrected
Yes
No
Unable to Perform
Audiometry:
Menses:
Menarche:
LMP:
Within Normal Limits
Abnormal
Unable to perform
Yes
No
F
/S
H
/C
:
AMILY
OCIAL
ISTORY
ONCERNS
(Current Concerns/ Follow-Up on Previously
Identified Concerns)
H
R
A
:
HEADDSS
GAPS
Other ____________________________________
EALTH
ISK
SSESSMENT
O
H
: White Spots on Teeth:
Yes
No
Daily Brushing 2x Daily/Flossing
Fluoride Supplement
RAL
EALTH
Last Dental Appointment: ____________
Future Dental Appointment Scheduled
Dental Home: Provider Name_______________
N
S
:
Nutritionally Balanced Diet
5 Servings of Fruits & Veggies
Junk Food
Soda/ Energy Drinks
UTRITIONAL
CREENING
Supplements _______________
Activity/Exercise (1hr/day)
Overweight
Underweight
Observation
Referral
D
S
:
Abstract Thinking
School Attendance
Sexuality/Orientation
EVELOPMENTAL
URVEILLANCE
Physical Growth and Development
Other ________________________
A
G
P
:
Emergency/911
Violence Prevention/Gun Safety
Drowning/Sun Safety
NTICIPATORY
UIDANCE
ROVIDED
Car/Seat Belt/Driving Safety
Safety at Home
Sports/Injury Prevention
Peer Refusal Skills
Age Appropriate Limits
Self-Control
Sex Education/STI/Resources
Availability of Family Planning Services
Social Interaction/Dating
Tobacco/Alcohol/Drugs/Rx Drugs/Inhalants
Risks of Tattoos/ Piercing
Education Goals/Activities
Job/Career Planning
Parenting Advice (As Appropriate)
Other ____________________________
S
-E
(O
/
):
Philosophical/Idealistic
Comfortable Body Image
OCIAL
MOTIONAL HEALTH
BSERVED BY CLINICIAN
PARENT REPORT
Self-Confident
Building Intimate/ Complex Relationships
Depression/Anxiety/Sleep Issues
Mood Changes
Other ________
COMPREHENSIVE PHYSICAL EXAM:
WNL
Abnormal (see notes below)
WNL
Abnormal (see notes below)
Skin/Hair/Nails
Lungs
Eyes/Vision
Abdomen
Ear
Genitourinary
Tanner Stage______
Mouth/Throat/Teeth
Extremities
Nose/Head/Neck
Spine
Heart
Neurological
ASSESSMENT/PLAN/FOLLOW UP
L
O
:
TB Skin Test
Hgb/Hct
Lipid Profile
Other _____________
ABS
RDERED
(If at Risk)
I
HepA
MMR
Varicella
HepB
Tdap
Influenza
Meningococcal
HPV
IPV
Td
MMUNIZATIONS
ORDERED:
Had Chicken Pox
Other ______________________
Given at Today’s Visit
Refused
Delayed
Deferred
Reason: ____________________________
Importance of Immunizations Discussed
Refusal Form Completed
Shot Record Updated/Entered in ASIIS
R
:
ALTCS
Audiology
CRS
DDD
Dental
PT
OB/GYN
OT
Speech
EFERRALS
Specialist:
Developmental
Behavioral
Other ________________________________________________
See Additional Supervisory
Date/Time
Clinician Name (Print)
Clinician Signature
NPI #
Note
Yes
No
Revised 04/01/2014
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