Children'S Special Health Services Flow Sheet
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1
2
31.
Last Name
First Name
MI
NC Department of Health and Human Services
2. Patient Number
-- H
Public Health Nursing and Professional Development
3.
Date of Birth
Month
Day
Year
CHILDREN’S SPECIAL HEALTH
4. Race
1. White
2. Black/African American
SERVICES FLOW SHEET
3. American Indian/Alaska Native
4. Asian
5. Native Hawaiian/Other Pacific Islander
6. Other
Ethnicity: Hispanic/Latino Origin?
Yes
No
7. English Speaking
Yes
No Language
5.
Gender
1. Male
2. Female
8. Interpreter?
Yes
No Who?
6.
County of Residence
9. ALLERGIES (food, drugs, insects, environmental)
10. CLINIC TYPE
____ Cardiology
____ Myelomeningocele
____ Neurology
____ Neuromuscular
____ Orthopedic
11. DATE/ AGE
/
/
12. Informant/Relationship
13. Current Problem; Complaint; or Parental Concerns
(Update at each visit)
♦
Date & Age of Onset (Update as needed)
♦
Course & Duration
(Update as needed)
♦
Effect of Treatment, if applicable
(Update as needed)
♦
Referral Source (Update as needed)
14. Immunization Status; Referral/Follow –Up
15. Current Provider for Well Child Care/Medical Home
♦
Date of Last Well Child Visit
16. Other Medical or Health Care Problems/Providers
17. Current Medications: Prescribed/ Over The Counter
18. Therapies: Speech, OT, PT, Nutrition, CSC,
Early Intervention, Special Education
19. Durable Medical Equipment: Type/Need/Repair
20. Signature
21. Education/Counseling Provided for Each
Diagnosis and Treatment
♦
Clinical Findings Including Diagnosis
♦
Treatment: Medication/Diagnostic Tests/Casting
♦
Special Therapy/Durable Medical Equipment
22. Referrals: Other Providers/Agencies/Immunizations
23. Date of Next Visit
24. Signature
DHHS 2809 (Revised 01/05)
PHNPD (Review 07/07)
=no significant problem; Y=yes; No=no; N=see notes; X=significant problem,
=item/test ordered; *=findings on lab slip
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