ࡱ> '*"#$%&a UVjbjbj .ee@C  z%z%z%z%z%D%%%%_>& (4>4>4>4r578xr[T^T^T^T^T^T^$adx^z%|8r5r5|8|8x^z%z%>4>44_*@*@*@|8Xz%>4z%>4r[*@|8r[*@*@RD"U>4pqA+z8FS&^[_0_$T[e9[eL"U[ez%:U$|8|8*@|8|8|8|8|8x^x^<|8|8|8_|8|8|8|8[e|8|8|8|8|8|8|8|8|8  @$: WELL CHILD EXAM EARLY CHILDHOOD: 4 YEARSAuthority: P.A. 116 of 1973 Completion: Required Consequences of non-completion: Non-compliance of licensing rules.Michigan Department of Health and Human ServicesWell Child Exam Date FORMTEXT      Patient NameDOBSexParent/Guardian Name FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      AllergiesCurrent Medications FORMTEXT       FORMTEXT      Prenatal/Family History FORMTEXT      WeightPercentileHeightPercentileBMIPercentileTemp.PulseResp.BP FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Interval History:(Include injury/illness, visits to other health care providers, changes in family or home) FORMTEXT      Nutrition FORMCHECKBOX Grains FORMTEXT      servings per day FORMCHECKBOX Fruit/Vegetables FORMTEXT      servings per day FORMCHECKBOX Whole Milk FORMTEXT      servings per day FORMCHECKBOX Meat/Beans FORMTEXT      servings per day FORMCHECKBOX City water FORMCHECKBOX Well water FORMCHECKBOX Bottled WaterWIC FORMCHECKBOX Yes FORMCHECKBOX NoElimination FORMCHECKBOX Normal FORMCHECKBOX AbnormalExercise AssessmentPhysical Activity FORMTEXT      minutes per daySleep FORMCHECKBOX Normal (8  12 hours) FORMCHECKBOX AbnormalAdditional area for comments on page 2Screening and ProceduresHearing FORMCHECKBOX Screening audiometry FORMCHECKBOX Parental observation/concernsVision FORMCHECKBOX Visual acuity FORMTEXT      R FORMTEXT      L FORMTEXT      Both FORMCHECKBOX Parental observation/concernsDevelopmental Surveillance FORMCHECKBOX Social-Emotional FORMCHECKBOX  Communicative FORMCHECKBOX Cognitive FORMCHECKBOX  Physical DevelopmentPsychosocial/Behavioral Assessment FORMCHECKBOX Yes FORMCHECKBOX NoScreening for Abuse FORMCHECKBOX Yes FORMCHECKBOX NoScreen If At Risk: FORMCHECKBOX IPPD FORMTEXT      (result) FORMCHECKBOX Hct or Hgb FORMTEXT      (result) FORMCHECKBOX Dyslipidemia FORMTEXT      (result)If not previously tested: FORMCHECKBOX Lead level FORMTEXT      mcg/dl (required forMedicaid)Immunizations: FORMCHECKBOX Immunizations Reviewed, Given & Charted if not given, document rationale FORMCHECKBOX Flu FORMCHECKBOX Other FORMTEXT       FORMCHECKBOX Acetaminophen FORMTEXT      mg. q. 4 hoursPatient Unclothed FORMCHECKBOX Yes FORMCHECKBOX NoReview of SystemsPhysical ExamSystemsNANA FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX General Appearance FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Skin/nodes FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Head FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Eyes FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Ears FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Nose FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Oropharynx FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Gums/palate FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Neck FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Lungs FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Heart/pulses FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Abdomen FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Genitalia FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Spine FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Extremities/hips FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Neurological  FORMCHECKBOX Abnormal Findings and CommentsIf yes, see additional note area on next pageResults of visit discussed with parent FORMCHECKBOX Yes FORMCHECKBOX NoPlan FORMCHECKBOX History/Problem List/Meds Updated FORMCHECKBOX Referrals FORMCHECKBOX WIC FORMCHECKBOX Head Start FORMCHECKBOX Children Special Health Care Needs FORMCHECKBOX Transportation FORMCHECKBOX Other FORMTEXT       FORMCHECKBOX Other FORMTEXT      Anticipatory Guidance/Health Education(check if discussed)Safety FORMCHECKBOX Appropriate care seat placed in back seat FORMCHECKBOX Smoke-free Home and care/smoke alarms FORMCHECKBOX Use bike helmet FORMCHECKBOX Teach stranger/pedestrian/playground safety and supervise child when outdoors FORMCHECKBOX Childproof home (matches, poisons, cigarettes, cleaners, medicines, knives) FORMCHECKBOX Gun safetyNutrition/physical activity FORMCHECKBOX Physical activity in a safe environment FORMCHECKBOX Family physical activity FORMCHECKBOX Limit screen time to 1-2 hours per day FORMCHECKBOX Offer variety of healthy foods FORMCHECKBOX Eat meals as a familyChild Development and Behavior FORMCHECKBOX Supervise tooth brushing FORMCHECKBOX Reinforce limits, provide choices FORMCHECKBOX Encourage child to talk about feelings FORMCHECKBOX Create a bedtime ritual that includes reading or calmly talking with your child FORMCHECKBOX Simple household tasks and responsibilities FORMCHECKBOX Praise good behavior and accomplishmentsFamily Support and Relationships FORMCHECKBOX Use correct terms for all body parts FORMCHECKBOX Explain good touch/bad touch and that certain body parts are private FORMCHECKBOX Listen/respect/show interest in activities FORMCHECKBOX Substance Abuse, Child Abuse, Domestic Violence Prevention, Depression FORMCHECKBOX Discuss community programs, preschool, head start, parenting groups, after school child careNext Well Check: 5 years of ageDevelopmental Surveillance on page 2. Page 3 required for Foster Care ChildrenMedical Provider Signature: PAGE 2  WELL CHILD EXAM  EARLY CHILDHOOD: 4 YearsDevelopmental Surveillance (This page may be used if not utilizing a Validated Developmental Screener)DateChild s NameDOB FORMTEXT       FORMTEXT       FORMTEXT      Developmental Questions and Observations Ask the parent to respond to the following statements about the child:YesNo FORMCHECKBOX  FORMCHECKBOX Please tell me any concerns about the way your child is behaving or developing FORMTEXT       FORMCHECKBOX  FORMCHECKBOX My child is learning how to play and share with others. FORMCHECKBOX  FORMCHECKBOX My child says positive things about themselves. FORMCHECKBOX  FORMCHECKBOX My child can tell when others are happy, mad or sad. FORMCHECKBOX  FORMCHECKBOX My child enjoys pretend play. FORMCHECKBOX  FORMCHECKBOX My child eats a variety of foods. FORMCHECKBOX  FORMCHECKBOX My child can sing a song. FORMCHECKBOX  FORMCHECKBOX My child can hop on one foot.Ask the parent to respond to the following statements:YesNo FORMCHECKBOX  FORMCHECKBOX I have people who assist me when I have questions or need help. FORMCHECKBOX  FORMCHECKBOX I am enjoying my time with my child. FORMCHECKBOX  FORMCHECKBOX I have time for myself, partner and friends. FORMCHECKBOX  FORMCHECKBOX I feel safe with my partner. FORMCHECKBOX  FORMCHECKBOX I feel confident in parenting.Provider to follow up as necessaryDevelopmental MilestonesAlways ask parents if they have concerns about development or behavior. (You may use the following screening list, or a standardized developmental instrument or screening tool).Child DevelopmentParent DevelopmentYesNoYesNoDresses Self FORMCHECKBOX  FORMCHECKBOX Appropriately disciplines child FORMCHECKBOX  FORMCHECKBOX Balances on each foot for 2 seconds FORMCHECKBOX  FORMCHECKBOX Parent is loving toward child FORMCHECKBOX  FORMCHECKBOX Says first and last name when asked FORMCHECKBOX  FORMCHECKBOX Positively talks, listens, and responds to child FORMCHECKBOX  FORMCHECKBOX Can draw a person with three parts FORMCHECKBOX  FORMCHECKBOX Parent uses words to tell child what is coming next FORMCHECKBOX  FORMCHECKBOX Aggressive or destructive behavior that threatens, harms or damages people, animals or property FORMCHECKBOX  FORMCHECKBOX Displays negativity, low self-esteem, or extreme dependence FORMCHECKBOX  FORMCHECKBOX Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. (Bright Futures: guidelines for Health Supervision of Infants, Children, and Adolescents.)Additional Notes from pages 1 and 2: FORMTEXT      Medical Provider SignatureMedical Provider Name (please print)AddressTelephone Number FORMTEXT       FORMTEXT       THIS PAGE IS REQUIRED FOR FOSTER CARE CHILDREN PAGE 3  WELL CHILD EXAM  EARLY CHILDHOOD: 4 YearsDateChild s NameDOB FORMTEXT       FORMTEXT       FORMTEXT      Name of person who accompanied child to appointment FORMCHECKBOX Parent FORMTEXT       FORMCHECKBOX Foster ParentPhone number of person who accompanied child to appointment FORMCHECKBOX Relative Caregiver (specify relationship) FORMTEXT       FORMTEXT       FORMCHECKBOX CaseworkerPhysical completed utilizing all Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements FORMCHECKBOX YesPlease attach completed physical form utilized at this visit FORMCHECKBOX NoIf no, please state reason physical exam was not completed FORMTEXT       FORMTEXT      Developmental, Social/Emotional and Behavioral Health ScreeningsAlways ask parents or guardian if they have concerns about development or behavior. 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Provide foster parent/child s caregiver with handout.FOSTER PARENT/CAREGIVER HANDOUT Your Child s Health at 4 years Milestones Ways your child is developing between 4 and 5 years of age. Counts on fingers and knows some letters Talks about what will happen tomorrow and what happened yesterday May begin to skip May have special friends and may tease or ignore some children Begins to know the difference between right and wrong and telling the truth and lying May want to be  just like you and may want to share in the things you do Uses words to solve simple problems and say what they re feeling For Help or More Information: Age Specific Safety Information: Call 202-662-0600 or go to  HYPERLINK "http://www.safekids.org/safety-basics/" http://www.safekids.org/safety-basics/ Car seat safety: Contact the Auto Safety Hotline at 888-327-4236 or online at  HYPERLINK "http://www.nhtsa.dot.gov" http://www.nhtsa.dot.gov To locate a Child Safety Seat Inspection Station, call 866-SEATCHECK (866-732-8243) or online at  HYPERLINK "http://www.seatcheck.org" www.seatcheck.org Poison Prevention: Call the Poison Control Center at 800-222-1222 or online at  HYPERLINK "http://www.mitoxic.org/pcc" www.mitoxic.org/pcc For information if you re concerned about your child s development: Contact Project Find at  HYPERLINK "http://www.projectfindmichigan.org/" http://www.projectfindmichigan.org/ or call 800-252-0052 Parenting skills or support: Call the Parents HELPline at 800-942-4357 or the Family Support Network of Michigan at 800-359-3722. Domestic Violence hotline: National Domestic Violence Hotline  800-799-SAFE (7233) or online at  HYPERLINK "http://www.ndvh.org" www.ndvh.org For help teaching your child about fire safety: Talk with firefighters at your local fire stationHealth Tips Your child will need some shots before starting school. Make sure you get them son. Be a role model for your child. Teach your child healthy habits by eating healthy foods, limiting screen time (T.V., computers, video games) and by encouraging family physical activity. Help your child get enough sleep so she will be happier and will learn easier! Put her to bed early so she gets 10 to 12 hours of sleep at night. Have a bedtime routine to calm your child before going to sleep. Read a story or talk together before bed. Each child develops in his own way, but you know your child best. If you think he is not developing well, call your child s doctor or nurse and tell them your concerns. Parenting Tips: Help your child know what to expect by making a calendar of pictures to show her activities for the day. Play active games (tag, ball, riding wheeled toys, climbing) Play board games and do puzzles Limit television and computer time to 1-2 hours a day Help your child feel good about himself and others: Praise your child every day Be clear about behaviors that are okay or not okay Help your child use words when she is feeling upset instead of hitting, kicking, biting or saying mean things Talk to your child about why teasing other children is wrong and what she should do instead If you feel very mad or frustrated with your child: Make sure your child in a safe place and walk away. Call a friend to talk about what you are feeling. Call the free Parent Helpline at 800-942-4357 (in Michigan). They will not ask your name, and can offer helpful support and guidance. The helpline is open 24 hours a day. Safety Tips Booster car seats are for big kids! Use a booster in the back seat with lap/shoulder belts. Make sure your child knows his address and phone number. Teach him how to call 911 in an emergency and to stay on the line if he has to call for help. Practice with a toy phone. Teach your child to stop, drop, and roll on the ground if her clothes catch on fire.From the Institute for Health Care Studies at Michigan State.The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.     DHS-1642 (Rev. 7-15) Previous edition obsolete. MS Word DHS-1642 (Rev. 7-15) Previous edition obsolete. 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