ࡱ>   =.Rbjbj .ee@AC  z%z%z%z%z%D%%%4,%c>& 3(44&4Z5v67le_GbGbGbGbGbGb$ehkbMz%8Z5Z588kbz%z%4&44cnDnDnD8z%4z%&4e_nD8e_nDnDWDmY4C[9~IX&Q_c0coXiN;iLmYiz%Y88nD88888kbkb?888c8888i888888888  @$: WELL CHILD EXAM EARLY ADOLESCENCE: 11  14 YearAuthority: 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      WeightPercentileLength/HeightPercentileBMIPercentileTemp.PulseResp.BP (if risk) 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 12 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 At Risk FORMCHECKBOX IPPD FORMTEXT       FORMCHECKBOX Hct or Hgb FORMTEXT       FORMCHECKBOX Dyslipidemia FORMTEXT       FORMCHECKBOX STI Screening FORMTEXT       FORMCHECKBOX Cervical Dysplasia FORMTEXT       FORMCHECKBOX Glucose FORMTEXT      Immunizations: FORMCHECKBOX Immunizations Reviewed, Given & Charted if 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 FORMCHECKBOX Swimming/Water Safety FORMCHECKBOX Use bike helmet/protective sporting gear FORMCHECKBOX Gun and weapon safetyNutrition FORMCHECKBOX Limit sugar and high fat food/drinks FORMCHECKBOX Healthy weight 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 a& adequate sleep FORMCHECKBOX Eat meals as a familyOral Health FORMCHECKBOX Schedule dental appointment FORMCHECKBOX Brush and floss teeth FORMCHECKBOX Limit sweets/sodaChild Development and Behavior FORMCHECKBOX Discuss puberty, development, contraception, STDs FORMCHECKBOX Normal sexual feelings/delaying sex FORMCHECKBOX Peer relationships FORMCHECKBOX Discuss family & household responsibilities FORMCHECKBOX Discuss ways to handle anger/conflict FORMCHECKBOX How to handle stress & disappointmentFamily Support and Relationships FORMCHECKBOX Substance Abuse, Child Abuse, Domestic Violence Prevention, Depression FORMCHECKBOX Know childs friends and their families FORMCHECKBOX Spend family time together FORMCHECKBOX Encourage positive interaction with siblings, teachers, friends and you FORMCHECKBOX Discuss limits and consequences FORMCHECKBOX Home, school, community rules FORMCHECKBOX Discuss school transitions & ability to adapt FORMCHECKBOX Encourage participation with peer activities 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 ChildrenProvider Signature: PAGE 2  WELL CHILD EXAM  EARLY ADOLESCENCE: 11  14 YEARS DEVELOPMENTAL SURVEILLANCE(This page may be used if not utilizing a Validated Developmental Screener)DatePatient 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 FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX My child eats breakfast every day. FORMCHECKBOX  FORMCHECKBOX My child is doing well in school. FORMCHECKBOX  FORMCHECKBOX My child has one or more close friends. FORMCHECKBOX  FORMCHECKBOX My child handles stress, anger, frustration well, most of the time. FORMCHECKBOX  FORMCHECKBOX My child seems rested when he/she awakens. FORMCHECKBOX  FORMCHECKBOX My child enjoys at least one activity and/or interest. FORMCHECKBOX  FORMCHECKBOX My child joins in family activities. FORMCHECKBOX  FORMCHECKBOX My childs activities are supervised by adults I trust. FORMCHECKBOX  FORMCHECKBOX Ask the parent to respond to the following statements:YesNo FORMCHECKBOX  FORMCHECKBOX I am proud of my child. FORMCHECKBOX  FORMCHECKBOX I talk to my child about alcohol, drugs, smoking and sexAsk the child to respond to the following statements:YesNo 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 enjoy school.*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 REQUIED FOR FOSTER CARE CHILDREN PAGE 3  WELL CHILD EXAM  EARLY ADOLESCENCE: 11  14 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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disability. PARENT/CAREGIVER HANDOUT Your Child s Health at 11  14 Years Milestones Ways your child is developing between 11 and 14 years of age. Most children get their second molars (back teeth) between 12 and 13. Talk with your dentist about sealants. Your child should floss daily. Between the ages of 10 and 14 many girls will begin to grow breasts and pubic hair and begin their periods. Between 10 and 14 many boys will begin to grow pubic hair and they may notice their scrotum and penis begin to change. Their voice may change and they may start to grow facial hair. Many boys and girls will have a growth spurt sometime between 10 and 15. Your child may have a hard time making good choices and may feel pushed to make bad choices so they feel like they fit in with kids at school. 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/ Domestic Violence hotline: National Domestic Violence Hotline  800-700-SAFE (7233) or online at  HYPERLINK "http://www.ndvh.org" www.ndvh.org Child sexual abuse, physical abuse, information and support: Contact the Child Abuse and Neglect Information Hotline or Parents HELPline at 800-942-4357. The Michigan Coalition Against Domestic & Sexual Violence at 517-347-7000 or online at  HYPERLINK "http://www.mcadsv.org" www.mcadsv.org Childhelp National Child Abuse Hotline 800-4-A-CHILD (800-422-4453) or online at  HYPERLINK "http://www.childhelp.org" www.childhelp.org 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/ Sexuality Information for teens:: (Planned Parenthood) http://www.plannedparenthood.org/info-for-teens/index.asp Children s Mental Health parent support and advocacy: Contact the Association of Children s Mental Health (ACMH) at 888-ACMH-KID (226-4543) or online at  HYPERLINK "http://www.acmh.mi.org" www.acmh.mi.org Churches or schools in your area may give classes on how to handle conflicts and/or anger. These can be useful skills for young teenagers.Health Tips Growth happens at different times for everyone. This can worry a child. If your child has not begun to have growth changes by age 14 talk with the doctor. Your child will need shots at this age. Talk with your child s doctor and make sure your child has had all of her shots. Your child should have 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 and your child enjoy. This is an important habit for your child to learn. It is important that your child eat healthy foods and snacks. Keep healthy snacks available. Your child needs fruit, vegetables, juice, and whole grains for growth and energy. Parenting Tips: Talk with your child about the changes in her body before and as the changes happen. Tell her these are signs of growing up and it can be exciting but can also be scary. Your child may be more emotional and sometimes rude or angry. Sometimes he feels sad, nervous or worried and things may not be going right. Talk with your child about his feelings Help him find a counselor if needed. Talk with and let your child know that sexual feelings are normal, but to delay having sex. Your child is growing mentally. You can help her thinking skills by asking her to solve problems. Talk about why teenagers should not use drugs and alcohol. Set a good example for your child. Teach your child how to deal with peer pressure. Encourage your child to join school or sporting activities. Safety Tips Cigarettes, drugs and alcohol are often offered to teenagers. Practice  saying no with your child. Teach your child gun safety. If you keep guns or rifles in your home, make sure they are unloaded and locked up. Teach your child to walk away if they see someone with a gun or other weapon and then report it to an adult they trust. Teach your child to always wear a seatbelt in the car and to sit in the back seat until they are adult height and weight. It s important for your child to use the correct sports equipment and safety gear. Make sure it fits your child well.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-1636 (Rev. 6-15) Previous edition obsolete. MS Word  PAGE 1 See Next Page DHS-1636 (Rev. 6-15) Previous edition obsolete. 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