ࡱ>  B0dbjbjOHOH .-"c-"cD@(((((4E(E(E(h-1E( kp(37([7[7[78n8<99 fwiwiwiwiwiwi$zm0pi)(Y988Y9Y9i(([7[74jyDyDyDY9F([7([7fyDY9fyDyD\lw_[7p\49R^*fj0 k-^Jp9pTw_"p(_Y9Y9yDY9Y9Y9Y9Y9ii@Y9Y9Y9 kY9Y9Y9Y9pY9Y9Y9Y9Y9Y9Y9Y9Y9 &:  WELL CHILD EXAM INFANCY: 6 MONTH VISITAuthority: 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      WeightPercentileLengthPercentileHCPercentileTemp.PulseResp.BP (if risk) FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Birth HistoryBirth WeightGestation FORMCHECKBOX VaginalComplications FORMCHECKBOX Yes FORMTEXT       FORMTEXT       FORMCHECKBOX C-Section FORMCHECKBOX No Interval History:(Include injury/illness, visits to other health care providers, changes in family or home) FORMTEXT      Apnea FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Monitor FORMCHECKBOX Breast every FORMTEXT      hours FORMCHECKBOX Formula FORMTEXT   oz every  FORMTEXT      hoursWith iron FORMCHECKBOX Yes FORMCHECKBOX NoType or brand FORMTEXT       FORMCHECKBOX City Water FORMCHECKBOX Well WaterSolids FORMCHECKBOX Yes FORMCHECKBOX NoElimination FORMCHECKBOX Normal FORMCHECKBOX AbnormalSleep FORMCHECKBOX Normal (6 8 hours) FORMCHECKBOX AbnormalAdditional area for comments on page 2WIC FORMCHECKBOX Yes FORMCHECKBOX NoMaternal Infant Health Program FORMCHECKBOX Yes FORMCHECKBOX NoScreening and Procedures FORMCHECKBOX Oral Health Risk Assessment FORMCHECKBOX Subjective Hearing-Parental observation/concerns FORMCHECKBOX Subjective Vision- Parental observation/concernsDevelopmental Surveillance FORMCHECKBOX Social-Emotional FORMCHECKBOX Communicative FORMCHECKBOX Physical Development FORMCHECKBOX CognitivePsychosocial/Behavioral Assessment FORMCHECKBOX Yes FORMCHECKBOX NoScreening for Abuse FORMCHECKBOX Yes FORMCHECKBOX NoScreening If At Risk FORMCHECKBOX IPPD FORMTEXT      (results) FORMCHECKBOX Lead level FORMTEXT      mcg/dlImmunizations: FORMCHECKBOX Immunizations Reviewed FORMCHECKBOX Immunizations Given & Charted  if not given, document rationale FORMCHECKBOX DTaP FORMCHECKBOX IPV FORMCHECKBOX HepB FORMCHECKBOX Hib FORMCHECKBOX PCV FORMCHECKBOX Rota FORMCHECKBOX Influenza 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/Fontanel 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 Early On FORMCHECKBOX Transportation FORMCHECKBOX Maternal Infant Health Program (MIHP) FORMCHECKBOX Children Special Health Care Needs FORMCHECKBOX Other referral FORMTEXT       FORMCHECKBOX Other FORMTEXT      Anticipatory Guidance/Health Education(check if discussed)Safety FORMCHECKBOX Appropriate car seat placed in back seat FORMCHECKBOX Keep home and car smoke-free FORMCHECKBOX Avoid burns (stove, etc.): lower water heater temperature FORMCHECKBOX Dont leave baby alone in tub/ high places FORMCHECKBOX Childproof home (hot liquids, alcohol, poisons, medicines, outlets, cords, small-sharp objects, plastic bags, safety locks) FORMCHECKBOX Keep in highchair/playpen when in kitchen FORMCHECKBOX Limit time in sun/use sunscreen on baby FORMCHECKBOX Dont use baby walkersNutrition FORMCHECKBOX Breastfeed or give iron-fortified formula FORMCHECKBOX Cup of water/juice limit juice FORMCHECKBOX Avoid foods that contribute to allergies FORMCHECKBOX Introduce solid foods at 4-6 months FORMCHECKBOX Wait one week or more to add new foodOral health FORMCHECKBOX Dont put baby to bed with bottle FORMCHECKBOX Discuss teething FORMCHECKBOX Assess fluoride/clean babys teeth dailyInfant Development FORMCHECKBOX Use upright seat so baby can see family FORMCHECKBOX Talk, sing, play music, and read to baby FORMCHECKBOX Daily and Bedtime Routine (put baby to bed awake) FORMCHECKBOX Safe Exploration Opportunities FORMCHECKBOX Put baby to sleep on back/Safe SleepFamily Support and Relationships FORMCHECKBOX Family Planning FORMCHECKBOX Chose responsible babysitters FORMCHECKBOX Substance Abuse, Child Abuse, Domestic Violence Prevention, Depression FORMCHECKBOX Consider parenting classes/support groups/PlaygroupsOther Anticipatory Guidance Discussed: FORMTEXT      Next Well Check: 9 months of ageDevelopmental Surveillance on Page 2 Page 3 required for Foster Care ChildrenMedical Provider Signature: PAGE 2  WELL CHILD EXAM  INFANCY: 6 Months  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 baby is behaving or developing: FORMTEXT       FORMCHECKBOX  FORMCHECKBOX My baby seeks comfort when upset. FORMCHECKBOX  FORMCHECKBOX My baby smiles and laughs. FORMCHECKBOX  FORMCHECKBOX My baby says things like da da or ba ba. FORMCHECKBOX  FORMCHECKBOX My baby eats some solid foods. FORMCHECKBOX  FORMCHECKBOX My baby sits with help/support. FORMCHECKBOX  FORMCHECKBOX My baby can pick up objects. FORMCHECKBOX  FORMCHECKBOX My baby likes to look at and be with me. FORMCHECKBOX  FORMCHECKBOX My baby rolls over.Ask the parent to respond to the following statements:YesNo FORMCHECKBOX  FORMCHECKBOX I am sad more often than I am happy. FORMCHECKBOX  FORMCHECKBOX I have people who help me when I get frustrated. FORMCHECKBOX  FORMCHECKBOX I am enjoying my baby more days than not. FORMCHECKBOX  FORMCHECKBOX I have a daily routine that seems to work FORMCHECKBOX  FORMCHECKBOX I keep in contact with family and friends. FORMCHECKBOX  FORMCHECKBOX I feel safe with my partner.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).Infant DevelopmentParent DevelopmentYesNoYesNoTurns to sounds/voices FORMCHECKBOX  FORMCHECKBOX Parent shows confidence with baby FORMCHECKBOX  FORMCHECKBOX Can be comforted most of the time FORMCHECKBOX  FORMCHECKBOX The parent comforts baby effectively FORMCHECKBOX  FORMCHECKBOX Smiles, squeals and laughs responsively FORMCHECKBOX  FORMCHECKBOX Parent and baby are interested in and respond to each other FORMCHECKBOX  FORMCHECKBOX Has no head lag when pulled to sit FORMCHECKBOX  FORMCHECKBOX Parent seems depressed, angry, tired, overwhelmed, or uncomfortable FORMCHECKBOX  FORMCHECKBOX Parent notices and responds to babys wants and needs 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 Staff SignatureMedical Provider SignatureTHIS PAGE IS REQUIRED FOR FOSTER CARE CHILDREN PAGE 3  WELL CHILD EXAM  INFANCY: 6 MonthsDateChild 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, Social/Emotional 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 Developmental Screening completed: Date FORMTEXT      Screener Used: FORMCHECKBOX ASQ FORMCHECKBOX ASQSE FORMCHECKBOX PEDS FORMCHECKBOX PEDSDM 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 the Institute for Health Care Studies at Michigan State Univers8:T< > < > R T V ` b d f z | ~   ǮǮǮǮ}Ǯj hWNUjhWNUj8hWNUjhWNU hWN5jhWNUmHnHujhWNUjhWNU h?V,hWNh!=hr(hWNCJaJh `5hWNhWNCJaJh>:h>:CJaJ1&8T< > y '$Ifgdm*ekd$$Ifl4Fv #,v  ,    4 lalf4ytm* G$Ifgdm* *$Ifgdm*gdk"   " GekdB$$Ifl4F, ,    4 lalf4ytm* E$Ifgdm* G$Ifgdm*?kdr$$Ifl4,,,4 lalf4ytm*" : < d }tttt E$Ifgdm*xkd$$Ifl4\n,h,4 lalf4ytm* G$Ifgdm*   }}*Rkd.$$Ifl40n,n2,4 lalf4ytm* G$Ifgdm*xkdv$$Ifl4\n,h,4 lalf4ytm* 2 4 6 @ B D F Z \ ^ h j n p       , . 0 : < > @ j hWNUj* hWNUj hWNUjV hWNUjhWNUjJhWNUj hWNUjhWNUmHnHujhWNUjhWNUhWN8 D l n Z?kd$$Ifl4,,,4 lalf4ytm* G$Ifgdm*Rkdt$$Ifl40n,n2,4 lalf4ytm* E$Ifgdm*   . : F R l G$Ifgdm*Gd$If]gdm* Gd$Ifgdm*?kd$$Ifl4,,,4 lalf4ytm* l n kd$$Ifl4 jM 5)##(,jmvusu{},((((4 lalf4ytm*n   > f j  (BVz 0$If^gdm* 0d$Ifgdm* G$Ifgdm*Ff E$If]^gdm* E$If^gdm* E$If]gdm* E$Ifgdm*@ T V X b d j l   (VXtvxzv#jPhhWNCJUaJhhWNCJaJjhhWNCJUaJhhWN5 hWN5j hWNUj< hWNUj hWNUjh hWNUjhWNUmHnHujhWNUj hWNUhWN*z"$&(DFHJ^`b~ӽzhӽ#jhhWNCJUaJ#jDhhWNCJUaJjhWNUjhWNUmHnHujXhWNUjhWNU hWN5hWN#jhhWNCJUaJhhWNCJaJjhhWNCJUaJhhWN5hhWNCJaJ' G$If^gdm* Gd$Ifgdm* G$Ifgdm*&:1(( E$Ifgdm* G$Ifgdm*kd<$$Ifl4ִ#(0*,^P8p,    4 lalf4ytV+ &J^` G$If^gdm* Gd$Ifgdm* G$Ifgdm* 0$If^gdm* 0d$Ifgdm*:5) Gd$Ifgdm*gdWNkd0$$Ifl4ִ#(0*,^P8p,    4 lalf4ytV+ ln󨚉}i}U}&jjhhWN5CJUaJ&jhhWN5CJUaJhhWN5CJaJ jhhWN5CJUaJhhWN56CJaJhWN56CJaJhhWNCJaJ"jhWNCJUaJmHnHujhWNCJUaJhWNCJaJjhWNCJUaJhWNhhWN5jl]Q Ed$Ifgdm*Jkd$$Ifl t44 lalp ytbW. 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Plays games like peek-a-boo Babbles, imitates vocalizations Responds to own name Feeds herself with fingers and starts to drink from cup Enjoys a daily routine Sits up well and may pull to stand Crawls, creeps, moves forward by scooting on bottom May be unsure of strangers May comfort self by sucking thumb or holding special toy May get upset when separated from familiar person For Help or More Information: Breast feeding, food and health information: Women, Infant, and Children (WIC) Program, call 800-26-BIRTH The National Womens Health Information Center Breastfeeding Helpline. Call 800-994-9662, or visit the website at:  HYPERLINK "http://www.4woman.gov/breastfeeding" www.4woman.gov/breastfeeding LA LECHE League 800-LALECHE (525-3243). Visit the website at  HYPERLINK "http://www.lalecheleague.org" www.lalecheleague.org Text4Baby for health and development information  HYPERLINK "http://www.text4baby.org" http://www.text4baby.org Car seat safety: Contact the Auto Safety Hotline at 888-327-4236. Visit the website at  HYPERLINK "http://www.safercar.gov" www.safercar.gov To locate a Child Safety Seat Inspection Station, call 1-866-SEATCHECK (866-732-8243) or online at  HYPERLINK "http://www.seatcheck.org" www.seatcheck.org Toy and Baby Product Safety: Consumers Product Safety Commission, 800-638-2772 or  HYPERLINK "http://www.cpsc.gov" www.cpsc.gov Prevention of Unintentional childhood injuries: National Safe Kids Campaign 202-662-0600 or  HYPERLINK "http://www.usa.safekids.org" www.usa.safekids.org If youre concerned about your childs development: Contact Early On Michigan at 800-327-5966 or Project Find at  HYPERLINK "http://www.projectfindmichigan.org/" http://www.projectfindmichigan.org/ or call 800-252-0052. For information about childhood immunizations: Call the National Immunization Program Hotlines at 800-232-4636 or online at http:/www.cdc.gov/vaccines. Domestic Violence hotline: National Domestic Violence Hotline 800-799-SAFE (7233) or online at  HYPERLINK "http://www.ndvh.org" http://www.ndvh.org Safety Tips: Make your home safe before for your baby starts to crawl. You will need to keep doing this for several years. Put away small objects and things that break Tap electric cords to the wall; put covers on outlets Put safety gates at the top and bottom of stairs Store poisons and pills in a locked cabinet Poison Control Center: 800-222-1222 Baby walkers cause more injury than any other baby product. Instead of a walker, use a seat without wheels or put your baby on his tummy on the floor. Health Tips: Signs your baby is ready to start solid food: She can sit up with little or no support She shows you she wants to try your food She can use her tongue to push food into her throat Your baby will let you know when he has had enough to eat. Stop feeding your baby when he spits food out, closes his mouth, or turns his head away. Let your baby begin to learn to drink from a cup. Put water, breast milk, or formula in it. Dont let your baby take a bottle to bed. Continue to put your baby to sleep on her back. Keep soft bedding and stuffed toys out of the crib. Make sure your baby sleeps by herself in a crib or portable crib. Parenting Tips: Show your baby picture books and talk about the pictures. Sing simple songs and say nursery rhymes over and over. Give your baby plenty of time to play on his tummy on the floor. Put toys just out of reach so he will try to crawl. Start play simple games together like Peek-a-Boo, Pat-a-Cake and So Big. Make regular times for eating, sleeping and playing with your baby. When you are a parent, you will be happy, mad, sad, frustrated, angry and afraid, at times. This is normal. If you feel very mad or frustrated: Make sure your child is in a safe place (like a crib) and walk away. Call a good 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. Calling does not make you weak; it makes you a good parent. 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-1641 (Rev. 6-15) Previous edition obsolete.  PAGE 1 See Next Page DHS-1641 (Rev. 6-15) Previous edition obsolete.  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