ࡱ>    :Rbjbj .ccFA  z%z%z%z%z%D%%%. :\%b >& (4(P4P4P456F7T]g`g`g`g`g`g`$df`5z%75577`z%z%P4P44aDDD7Fz%P4z%P4]D7]DD)U0UWP4p3o7FYV$q]a0b}Vg&8LgHUWgz%mW77D77777``r>X777b7777g777777777  @$: WELL CHILD EXAM EARLY CHILDHOOD: 5 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 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 Meats/Beans FORMTEXT      servings per day FORMCHECKBOX City water FORMCHECKBOX Well water FORMCHECKBOX Bottle WaterElimination FORMCHECKBOX Normal FORMCHECKBOX AbnormalExercise AssessmentPhysical Activity: FORMTEXT      Minutes per daySleep FORMCHECKBOX Normal (8-12 hours) FORMCHECKBOX AbnormalAdditional area for comments on page 2Screening and Procedures FORMCHECKBOX Urinalysis (Required for Medicaid)Hearing FORMCHECKBOX Screening audiometry  FORMCHECKBOX Parental observation/concernsVision FORMCHECKBOX Visual acuity FORMTEXT   R FORMTEXT   L FORMTEXT   Both FORMCHECKBOX Parental observation/concernsDevelopmental Screening FORMCHECKBOX Social Emotional FORMCHECKBOX Communicative FORMCHECKBOX Cognitive FORMCHECKBOX Physical DevelopmentPsychosocial/Behavioral Assessment FORMCHECKBOX Yes FORMCHECKBOX NoScreening for Abuse FORMCHECKBOX Yes FORMCHECKBOX NoScreen If Risk: FORMCHECKBOX IPPD FORMTEXT      (result) FORMCHECKBOX Hct or Hgb FORMTEXT      (result)If not previously tested: FORMCHECKBOX Lead level FORMTEXT      mcg/dl (for 6 year olds-Required for Medicaid)Immunizations: FORMCHECKBOX Immunizations Reviewed, Given & Charted if not given, document rationale FORMCHECKBOX DTaP FORMCHECKBOX IPV FORMCHECKBOX MMR FORMCHECKBOX Influenza FORMCHECKBOX Varicella or Chicken Pox Date: FORMTEXT       FORMCHECKBOX MCIR checked/updated 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 Growth and DevelopmentIf 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 Teach child to wash hands, wipe nose w/tissue FORMCHECKBOX Working smoke detectors/fire escape plan FORMCHECKBOX Appropriate booster seat placed in backs seat FORMCHECKBOX Carbon monoxide detectors/alarms FORMCHECKBOX Pool/tub/water safety swimming lessons FORMCHECKBOX Use bike/skating helmet FORMCHECKBOX Supervise near pets, mowers, driveways, streets FORMCHECKBOX Gun safety FORMCHECKBOX Child proof home (matches, poisons, cigarettes, cleaners, medicines, knives)Nutrition/physical activity FORMCHECKBOX Provide a healthy breakfast every morning FORMCHECKBOX Family meals. FORMCHECKBOX Offer variety of healthy foods and include 5 servings of fruits &veggies every day FORMCHECKBOX Limit TV, video, and computer games FORMCHECKBOX Physical activity & adequate sleepOral Health FORMCHECKBOX Schedule dental appointment FORMCHECKBOX Supervise tooth brushing FORMCHECKBOX Discuss flossing, fluoride, sealantsChild Development and Behavior FORMCHECKBOX Establish routines and traditions FORMCHECKBOX Explain good touch/bad touch and that certain body parts are private FORMCHECKBOX Reinforce limits, provide choices FORMCHECKBOX Simple household tasks & responsibilities FORMCHECKBOX Praise good behavior and actions FORMCHECKBOX Family Rules/Respect/Right from wrong FORMCHECKBOX Encourage expression of feelingsFamily Support and Relationships FORMCHECKBOX Listen/respect/show interest in childs activities FORMCHECKBOX Substance Abuse, Child Abuse, Domestic Violence Prevention, Depression FORMCHECKBOX Discuss community and recreational programs, school, and after school care FORMCHECKBOX Volunteer and become involved with school FORMCHECKBOX Meet your childs school teachers FORMCHECKBOX Know childs friends and their familiesNext Well Check:6 years of ageDevelopmental Surveillance on Page 2 Page 3 required for Foster Care ChildrenMedical Provider Signature: PAGE 2 WELL CHILD EXAM EARLY CHILDHOOD: 5 Years Developmental Surveillance (This page may be used if not utilizing a Validated Developmental Screener)DateChild s NameDOB FORMTEXT       FORMTEXT       FORMTEXT      Developmental Questions and ObservationsAsk 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 does what I ask them to do most of the time. FORMCHECKBOX  FORMCHECKBOX My child says positive things about themselves. FORMCHECKBOX  FORMCHECKBOX My childs shows an ability to understand the feelings of others. FORMCHECKBOX  FORMCHECKBOX My child can tell a story using full sentences. FORMCHECKBOX  FORMCHECKBOX My child follows simple directions. FORMCHECKBOX  FORMCHECKBOX My child can recognize most letters and is able to print some letters. FORMCHECKBOX  FORMCHECKBOX My child can balance on one foot.Ask the parent to respond to the following statements:YesNo FORMCHECKBOX  FORMCHECKBOX I have people I can turn to when I have questions or need help FORMCHECKBOX  FORMCHECKBOX I feel good about my child starting school. FORMCHECKBOX  FORMCHECKBOX I am sad more often than I am happy. FORMCHECKBOX  FORMCHECKBOX I feel confident in parenting.Provider to follow up as necessary.Developmental 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 DevelopmentYesNoYesNoDress without supervision FORMCHECKBOX  FORMCHECKBOX Appropriate discipline FORMCHECKBOX  FORMCHECKBOX Skips and hops FORMCHECKBOX  FORMCHECKBOX Parent is loving toward child FORMCHECKBOX  FORMCHECKBOX Draws a person with head, body, arms and legs FORMCHECKBOX  FORMCHECKBOX Positively talks, listens, and responds to child FORMCHECKBOX  FORMCHECKBOX Appears unusually fearful, anxious or withdrawn 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 Parent encourages child to speak for him or her self, share ideas, wants and needs. FORMCHECKBOX  FORMCHECKBOX Displays negativity, low self-esteem, or extreme dependencyPlease 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 Staff SignatureMedical Provider SignatureTHIS PAGE IS REQUIRED FOR FOSTER CARE CHILDREN PAGE 3  WELL CHILD EXAM  EARLY CHILDHOOD: 5 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      Developmental, Psychosocial, and Behavioral Health Screenings (must use validated tool)Always ask parents or guardian if they have concerns about development or behavior. (You must use a standardized developmental instrument or screening tool as required by the Michigan Department of Health and Human Services [prior to April 2015 Michigan Department of Community Health and Michigan Department of Human Services]).Validated Standardized Behavioral Screening completed: Date FORMTEXT      Screener Used: FORMCHECKBOX Pediatric Symptom Checklist (PSC) FORMCHECKBOX ASQ FORMCHECKBOX ASQSE FORMCHECKBOX PEDS FORMCHECKBOX PEDSDM (PEDS/DM  FORMCHECKBOX Other tool: FORMTEXT      Score: FORMTEXT      Referral Needed: FORMCHECKBOX No FORMCHECKBOX YesReferral Made: FORMCHECKBOX No FORMCHECKBOX YesDate of Referral: FORMTEXT      Agency: FORMTEXT      Current or Past Mental Health Services Received: FORMCHECKBOX No FORMCHECKBOX Yes(if yes please provide name of provider)Name of Mental Health Provider: FORMTEXT      EPSDT Abnormal results: FORMTEXT      Special Needs for Child (e.g., DME, therapy, special diet, school accommodations, activity restrictions, etc.): FORMTEXT      Medical Staff Signature DateMedical Provider Name (Please print) FORMTEXT      AddressTelephone Number FORMTEXT       FORMTEXT      This form was developed by tT6 8 < @ @ B V X Z d f h j ~ " 6 8 : D F H J jh/^Uj"h/^Ujh/^UjNh/^Ujh/^U h/^5 h?V,h/^jh/^UmHnHujh/^Ujh/^UhB h.h/^h/^7"DT< > @ ~u '$Ifgd/^ekd$$Ifl4Fl (#,l x     4 lalf4yt/^ $Ifgd/^ *$Ifgd/^ *$Ifgd. 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Provide childs caregiver/foster parent with handout.PARENT HANDOUT Your Childs Health at 5 Years Milestones Ways your child is developing between 5 and 6 years of age. Recognizes her own printed name May form special groups of friends and may be jealous of others Takes turns Feels proud of himself and his accomplishments Helps with family chores Able to follow rules at home and school and respect authority Beginning to learn rules for simple games Riding a bicycle and learning to swim For Help or More Information: Child sexual abuse, physical abuse, information and support: Contact the Child Abuse and Neglect Information Hotline or Parents HELPline at 1-800-942-4357 The Michigan Coalition Against Domestic & Sexual Violence at 1-517-347-7000 or online at HYPERLINK "\\\\HCS084VSNBPF008\\DHS2\\Lansing\\Shared\\OSD\\Mrbig2\\Forms\\DHS Forms\\0300-0399\\www.mcadsv.org"www.mcadsv.org Childhelp National Child Abuse Hotline 1-800-4-A-CHILD (1-800-422-4453) or online at HYPERLINK "\\\\HCS084VSNBPF008\\DHS2\\Lansing\\Shared\\OSD\\Mrbig2\\Forms\\DHS Forms\\0300-0399\\www.childhelp.org"www.childhelp.org Age Specific Safety Information: Call 1-202-662-0600 or go to  HYPERLINK "http://www.safekids.org/safety-basics/" http://www.safekids.org/safety-basics/ Domestic Violence hotline: National Domestic Violence Hotline (800) 799-SAFE (7233) or online at HYPERLINK "\\\\HCS084VSNBPF008\\DHS2\\Lansing\\Shared\\OSD\\Mrbig2\\Forms\\DHS Forms\\0300-0399\\www.ndvh.org"www.ndvh.org Car seat safety: Contact the Auto Safety Hotline at 1-888-327-4236 or online at  HYPERLINK "www.nhtsa.dot.gov" www.nhtsa.dot.gov To locate a Child Safety Seat Inspection Station, call 1-866-SEATCHECK (866-732-8243) or online at www.seatcheck.org Poison Prevention: Call the Poison Control Center at 1-800-222-1222 or online at  HYPERLINK "www.mitoxic.org/pcc" www.mitoxic.org/pcc Parenting skills or support: Call the Parents Hotline at 1-800-942-4357 or the Family Support Network of Michigan 15 1-800-359-3722. For help teaching your child about fire safety: Talk with firefighters at your local fire station. Health Tips: Continue to take your child for a check-up each year with a doctor or nurse. Your child will still need you to help get all of their teeth brushed well. Make sure to take your child for a dental check-up at least once a year. Parenting Tips: Eat together as often as possible. Turn off the TV and the phone, and enjoy each other. Listen when your child talks to you. Look at him and pay attention. Then answer or ask about his ideas. Let him know that what he thinks and says is important to you. Talk with your child about how to avoid sexual abuse. Teach your child about privacy and teach that adults shouldnt ask her to keep secrets from you or show their private parts or ask to see your childs private parts. Tell your child she should say no and that she should tell you if anyone tries to harm her. Teach your child what to do and not do when theyre angry. Limit TV or computer time so your child also has time for books and active play. Read storybooks with him daily. Take your child outside often to play. Help your child feel good about herself 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 is in a safe place and walk away. Call a friend to talk about what you are feeling. Call the free Parent Helpline at 1-800-942-4357 (in Michigan). They will not ask your name and can offer helpful support and guidance. The helpline is open 24 hours a day. Calling does not make you weak; it makes you a good parent. Safety Tips Booster car seats are for big kids! Use a booster in the back seat with lap/shoulder belts. Your child should always wear a lifejacket around water, even after he has learned to swim. Your child should always wear a lifejacket around water, even after she has learned to swim. Always watch your child closely when she is near the street. Children are not ready to ride bikes safely on streets or cross streets without an adult until they reach at least age 9. Your child is not old enough to always behave safely around vehicles. Teach your child to never touch a gun. If your child finds one, she should tell an adult right away. Make sure any guns in your home are unloaded and locked up.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.From the Institute for Health Care Studies at Michigan State University.     DHS-1635 (Rev. 6-15) Previous edition obsolete. MS Word  PAGE 1 See Next Page DHS-1635 (Rev. 6-15) Previous edition obsolete. 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