ࡱ> %( !"#$ ,mbjbjyy  E  z%z%z%z%z%D%%%>&B(d%bt.&=(N=N=f=>d@PAxrrrrrrr$VvyrMz%A>>AArz%z%N=f=4t.L.L.LAz%N=z%f=r.LAr.L.L2iqlN=Cj.r2t0btjyELy\qlyz%l AA.LAAAAArrHXAAAbtAAAAyAAAAAAAAA  @$: WELL CHILD EXAM ADOLESCENCE: 15  18 YearAuthority: P.A. 116 of 1973 Completion: Required Consequences of non-completion: Non-compliance of licensing rules.Michigan Department of Health and Human ServicesWell 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 WaterElimination FORMCHECKBOX Normal FORMCHECKBOX AbnormalExercise AssessmentPhysical Activity FORMTEXT      minutes per daySleep FORMCHECKBOX Normal FORMCHECKBOX AbnormalMenstrual FORMCHECKBOX Premenarchal FORMCHECKBOX Normal FORMCHECKBOX AbnormalAdditional area for comments on page 2Screening and Procedures FORMCHECKBOX Urinalysis (Required for Medicaid sexually active adolescent males and females)Hearing FORMCHECKBOX Parental observation/concernsVision FORMCHECKBOX Visual acuity (at 15 & 18 years) 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 NoAlcohol & Drug Use (risk assessment) FORMCHECKBOX Yes FORMCHECKBOX NoScreening for Abuse FORMCHECKBOX Yes FORMCHECKBOX NoScreen If Risk: FORMCHECKBOX IPPD FORMTEXT      (result) FORMCHECKBOX Hct or Hgb FORMTEXT      (result) FORMCHECKBOX Dyslipidemia FORMTEXT      (result) (1X 18-20) FORMCHECKBOX STI Screening FORMTEXT      (result) FORMCHECKBOX Cervical Dysplasia FORMTEXT      (result) FORMCHECKBOX Glucose FORMTEXT      Immunizations: FORMCHECKBOX Immunizations Reviewed, Given & ChartedIf necessary but not given, document rationale FORMCHECKBOX Tdap FORMCHECKBOX HPV FORMCHECKBOX Flu FORMCHECKBOX MCV4 FORMCHECKBOX MCIR checked/updated Patient 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 Normal Growth and Development FORMCHECKBOX Tanner Stage FORMTEXT       FORMCHECKBOX Abnormal Findings and CommentsIf yes, see additional note area on next pageResults of visit discussed with child/parent FORMCHECKBOX Yes FORMCHECKBOX NoPlan FORMCHECKBOX History/Problem List/Meds Updated FORMCHECKBOX Referrals FORMCHECKBOX Children Special Health Care Needs FORMCHECKBOX Transportation FORMCHECKBOX Other FORMTEXT       FORMCHECKBOX Other FORMTEXT      Anticipatory Guidance/Health Education(check if discussed)Safety FORMCHECKBOX Avoid alcohol, tobacco, drugs, inhalants FORMCHECKBOX Make a plan with child if in unsafe situation FORMCHECKBOX Seat belt use for self and passengers FORMCHECKBOX Responsible Driving/follow speed limits FORMCHECKBOX Swimming/Water Safety FORMCHECKBOX Use bike helmet/protective sporting gear FORMCHECKBOX Gun and weapon safety FORMCHECKBOX Learn to protect self from abuse FORMCHECKBOX Limit time in sun-use sunscreenNutrition/physical activity FORMCHECKBOX Healthy weight/body image/dieting FORMCHECKBOX Limit TV, video, and computer games FORMCHECKBOX Physical activity & adequate sleep FORMCHECKBOX Eat meals as a familyOral Health FORMCHECKBOX Schedule dental appointment FORMCHECKBOX Brush and floss teeth FORMCHECKBOX No smoking/chewing tobaccoDevelopment and Behavior FORMCHECKBOX Increased responsibility for own health care FORMCHECKBOX Self breast/Testicular exam FORMCHECKBOX Handling stress & disappointment FORMCHECKBOX Discuss development FORMCHECKBOX Normal sexual feelings FORMCHECKBOX Preventing pregnancy and STIs FORMCHECKBOX Avoid risky or violent situations FORMCHECKBOX Healthy dating relationships FORMCHECKBOX Feeling sad/angry/fearful FORMCHECKBOX Handling depression-suicideFamily Support and Relationships FORMCHECKBOX Substance Abuse, Child Abuse, Domestic Violence Prevention, Depression FORMCHECKBOX Know who your teen spends time with FORMCHECKBOX Spend family time together FORMCHECKBOX Home, school, community rules FORMCHECKBOX Respect others FORMCHECKBOX Discuss future plans/college/career FORMCHECKBOX School frustrations/dropping out FORMCHECKBOX Encourage to volunteer/participate with religious, school or community activitiesNext Well Check:  FORMTEXT       years of ageDevelopmental Surveillance on Page 2 Page 3 required for Foster ChildrenMedical Provider Signature: PAGE 2  WELL CHILD EXAM  ADOLESCENCE: 15  20 YEARS DEVELOPMENTAL SURVEILLANCE(This page may be used if not utilizing a Validated Developmental Screener)DatePatient NameDOB FORMTEXT       FORMTEXT       FORMTEXT      Developmental Questions and ObservationsYou may use the following screening list, or an age appropriate standardized developmental instrument or screening tool.As the patient to respond to the following statements:YesNo FORMCHECKBOX  FORMCHECKBOX Please tell me any questions concerns you have today: FORMTEXT       FORMCHECKBOX  FORMCHECKBOX I eat breakfast every day. FORMCHECKBOX  FORMCHECKBOX I am happy with how I am doing in school and/or at work. FORMCHECKBOX  FORMCHECKBOX I have one or more close friends. FORMCHECKBOX  FORMCHECKBOX I feel rested when I wake up. FORMCHECKBOX  FORMCHECKBOX I participate in at least one activity and/or interest other than school and work. FORMCHECKBOX  FORMCHECKBOX I do things with my family. FORMCHECKBOX  FORMCHECKBOX I feel good about my friends and school. FORMCHECKBOX  FORMCHECKBOX I know what to do when I feel angry, stressed, or frustrated. FORMCHECKBOX  FORMCHECKBOX I have someone I can talk to. FORMCHECKBOX  FORMCHECKBOX I have questions about sexuality. FORMCHECKBOX  FORMCHECKBOX I get some physical activity every day. FORMCHECKBOX  FORMCHECKBOX I sometimes feel really down and depressed. FORMCHECKBOX  FORMCHECKBOX I sometimes feel very nervous.If the parent is present, ask the parent to respond to the following statements: FORMCHECKBOX  FORMCHECKBOX I am proud of my child. FORMCHECKBOX  FORMCHECKBOX I talk to my child about alcohol, drugs, and smoking. FORMCHECKBOX  FORMCHECKBOX My childs school work matches his/her future goals. FORMCHECKBOX  FORMCHECKBOX My childs school work matches my future goals for him/her. FORMCHECKBOX  FORMCHECKBOX I talk to my child about sexuality and our familys values regarding sex. FORMCHECKBOX  FORMCHECKBOX I monitor my childs activities and social life.*Please note: Formal development 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  ADOLESCENCE: 15  18 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 CaseworkerA physical exam, including developmental, psychosocial, and behavioral health screening, must be completed utilizing all Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements. Please attach the completed physical form utilized at this visit.Developmental, Psychosocial, and Behavioral Health Screenings (must use validated tool)Always ask child, parents and/or guardian if they have concerns about development or behavior. 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lalf4yt)5LLM8M:MMnMpMrMMTK E$Ifgdbkd$$Ifl40 , "  4 lalf4p yt)5 0$Ifgds?kd$$Ifl4,,4 lalf4yt)5MMMMN>>>>>>>>>2?4?8?:?l?n?p???????????????A`ABDDDDDDDļͱͼ͘挄yqh:h>:5h>:h>:CJaJh>CJaJh>:CJaJhO'j h)5Ujh)5UmHnHujh)5Ujh)5Uhe%eh)5CJh)5j*hUhUh>:hJjhUjhUmHnHu,MMMM>>v?kdQ$$Ifl4,,4 lalf4yt)5 0$Ifgds?kd$$Ifl4p,,4 lalf4yt)5cial diet, school accommodations, activity restrictions, etc.): FORMTEXT      Medical Provider SignatureMedical Provider Name (please print)AddressTelephone Number FORMTEXT       FORMTEXT      This form was developed by the Institute for Health Care Studies at Michigan State University in collaboration with the Michigan Medicaid managed care plans, Michigan Department of Health and Human Services, Michigan Association of Health Plans, and Michigan Association of Local Public Health.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.  PATIENT/PARENT/CAREGIVER HANDOUT Your Child s Health at 15  18 Years Milestones Your development between 15 and 18 years of age. You will keep making more decisions for yourself, plan for your life after high school, and discover new skills and talents. This can be an exciting time for you but also can be very emotional. This is part of the growing process. You can learn to manage stress or anger by taking a class with a friend or your parents. Teens face many tough choices and may feel more pressures to make the wrong choice. This is an important time to talk to friends, parents, family members and trusted teacher to help you learn to make the right choices. For Help or More Information: Safety Information: Call 1-202-662-0600 or go to HYPERLINK "http://www.safekids.org/safety-basics/"http://www.safekids.org/safety-basics/ Crisis Intervention/Suicide Prevention Information: The National Crisis 24/7 Helpline at 1-800-999-9999 or visit  HYPERLINK "http://www.nineline.org/" http://www.nineline.org/ Girls & Boys Town 24/7 Suicide and Crisis Line: 800-448-3000 or visit  HYPERLINK "www.girlsandboystown.org/hotline" www.girlsandboystown.org/hotline Sexuality Information for teens: (Planned Parenthood)  HYPERLINK "http://www.plannedparenthood.org/info-for-teens/index.asp" /www.plannedparenthood.org/info-for-teens/index.asp Gambling: Michigan Department of Community Health Problem Gambling Help-line: (800) 270-7117 (24-hours) National Council on Problem Gambling 24 hour confidential Hotline Number: (800) 522-4700 or online at  HYPERLINK "www.ncpgambling.org" www.ncpgambling.org AIDS Hotlines: Michigan AIDS Hotline (800) 872-2437 AIDS.GOV website online at  HYPERLINK "www.aids.gov" www.aids.gov National AIDS Hotline: 1-800-CDC-INFO (1-800-232-4636) or online at  HYPERLINK "www.cdc.gov" www.cdc.gov 24-Hour Hotline (Public Health Service): 1-800-342-2437 Eating Disorders: Call the Eating Disorder Hotline 1-800-931-2237 or visit  HYPERLINK "http://www.mantionaleatingdisorders.org/" http://www.mantionaleatingdisorders.org/ Domestic Violence hotline: National Domestic Violence Hotline  (800) 700-SAFE (7233) or online at  HYPERLINK "http://www.ndvh.org" www.ndvh.org General information for teens and their parents: Provides information for teens and parents of teen on many teen topics.  HYPERLINK "http://www.kidshealth.org/" http://www.kidshealth.org/Health Tips Talk with you doctor at each visit about your health and learn what to do when you have a cold, an earache, or the flu. You should have regular health, vision and dental check-ups. You need at least 8 hours of sleep each night to do your best at school, work or when driving. A healthy diet is important. You need certain food to help you grow during your teen years. If you are worried about your weight, check with your doctor. Diet for weight loss should be done only with a doctor or nurse s help. Exercise, healthy foods and fewer snacks are the best way to lose weight. Make a goal to be physically active at least 60 minutes each day. It doesn t have to be all at once. Find activities that you enjoy. Learn about sexuality, abstinence, sexually transmitted infections and birth control. Be sure you know how and why to say  NO to sex. Talk to your parents, doctor, nurse or adult advisor about making sexual decisions. Everyone feels depressed sometimes. It can be serious so see your doctor or find a counselor if you, or someone you know has several of the following signs for more than two weeks: Depressed/irritable mood most of the day, nearly every day Loss of interest or pleasure in usual activities Noticeable change in appetite or weight (when not dieting or trying to gain weight) Trouble sleeping or sleeping too much Speaking and/or moving with unusual speed or slowness Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive guilt Decreased ability to think or concentrate, or unable to make decisions, nearly every day Thoughts of death, suicide, wishes to be dead or suicide attempts Abusing drugs, alcohol or other substances Safety Tips Use safety equipment, helmets, pads and seat belts. Driving is most risky for teenagers when they have other teens in the car. You and your parents should agree on clear rules about driving, especially with your friends. Never drive drunk or ride with anyone who has been drinking. Remember,  Friends don t let friends drive drunk. They also don t let friends ride with a drunk. Learn gun safety. Never play around with guns. If there are guns or rifles in your home, make sure they are unloaded and locked up.From the Institute for Health Care Studies at Michigan State University.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-1637 (Rev. 8-15) Previous edition obsolete. MS Word  PAGE 1 See Next Page DHS-1637 (Rev. 6-15) Previous edition obsolete. 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