CHILDREN’S SERVICES HANDBOOK

APPENDIX A: THSTEPS FORMS A.1 Claim Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-296 A.2 Child Health Clinical Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-296 A.3 Guidelines for Tuberculosis Skin Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-297 A.4 Laboratory Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-297 CH.37 Child Health History (2 Pages). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-298 CH.38 Child Health Record (Birth–1 Month) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-300 CH.39 Child Health Record (2–6 Months) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-302 CH.40 Child Health Record (7–12 Months) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-304 CH.41 Child Health Record (13 Months–2 Years) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-306 CH.42 Child Health Record (3–5 Years) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-308 CH.43 Child Health Record (6-10 Years) (2 Pages). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-310 CH.44 Hearing Checklist for Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-312 CH.45 Hearing Checklist for Parents (Spanish). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-313 CH.46 Mental Health Interview Tool/Referral Form (Ages 0–2 Years) . . . . . . . . . . . . . . . . . . . . . . . . CH-314 CH.47 Mental Health Interview Tool/Referral Form (Ages 3–9 Years) . . . . . . . . . . . . . . . . . . . . . . . . CH-315 CH.48 Mental Health Interview Tool/Referral Form (Ages 10–12 Years). . . . . . . . . . . . . . . . . . . . . . CH-316 CH.49 Mental Health Interview Tool/Referral Form (Ages 13–20 Years). . . . . . . . . . . . . . . . . . . . . . CH-317 CH.50 Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages) . . . . . . . . . . . . . . . . . . CH-318 CH.51 Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish) . . . . . . . . . . . . . . . . CH-320 CH.52 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . CH-322 CH.53 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish) . . . . . . . . . . . . CH-324 CH.54 Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages). . . . . . . . . . . . . . . . . . . . CH-326 CH.55 Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish) . . . . . . . . . . CH-328 CH.56 Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages). . . . . . . . . . . . . . . . . . . . CH-330 CH.57 Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish) . . . . . . . . . . CH-332 CH.58 Risk Assessment for Lead Exposure: Parent Questionnaire, Form Pb-110 (2 Pages) . . . . CH-334 A.5 Tuberculosis Screening and Education Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-336 CH.59 TB Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-337 CH.60 Cuestionario Para la Detección de Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-338 CH.61 How to Determine TB Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-339 CH.62 PPD Agreement for Texas Health Steps Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-340 CH.63 TVFC Patient Eligibility Screening Record. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-341 CH.64 TVFC Patient Eligibility Screening Record (Spanish) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-342 CH.65 TVFC Provider Enrollment (3 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-343 CH.66 TVFC Questions and Answers (3 Pages). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-346

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A.1 Claim Forms Providers must order CMS-1500 and ADA Dental Claims Forms from the vendor of their choice. Copies cannot be used. Claims filing instructions and examples of the claim forms are located in Section 6: Claims Filing (Vol. 1, General Information). Refer to: Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information). Subsection 6.5.3, “CMS-1500 Blank Paper Claim Form” in Section 6, “Claims Filing” (Vol. 1, General Information). Subsection 6.7, “2006 American Dental Association (ADA) Dental Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information).

A.2 Child Health Clinical Records The use of forms ECH 1–7 is optional. These forms were developed to help providers document all components of the medical checkup. THSteps requires the following forms: Hearing Checklist for Parents, Tuberculosis (TB) Questionnaire, Risk Assessment for Lead Exposure, and the DSHS State Laboratory forms. All of these forms can be downloaded from the THSteps website at http://dshs.state.tx.us/thsteps/forms.shtm. Lead poisoning screening questionnaires can be downloaded from the Texas Childhood Lead Poisoning Prevention Program (TX CLPPP) website at www.dshs.state.tx.us/lead/providers.shtm. Forms CH-9W through CH-12W may be downloaded from the Centers for Disease Control and Prevention (CDC) website at www.cdc.gov/growthcharts/clinical_charts.htm. Stock Number

Form

CH-9W

Growth Chart - Infant Girl

CH-10W

Growth Chart - Infant Boy

CH-11W

Growth Chart - Child Girl

CH-12W

Growth Chart - Child Boy

ECH-1

Child Health History

ECH-2

Preventive Health Visit - Birth to 1 Month

ECH-3

Preventive Health Visit - 2–6 Months

ECH-4

Preventive Health Visit - 7–12 Months

ECH-5

Preventive Health Visit - 13 Months to 2 Years

ECH-6

Preventive Health Visit - 3–5 Years

ECH-7

Preventive Health Visit - 6–10 Years Form Pb-110, Risk Assessment for Lead Exposure TB Questionnaire

For forms for documenting medical checkups for adolescents, please refer to sources such as Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (2nd edition, revised), located at www.brightfutures.org or the Guidelines for Adolescent Preventive Services (GAP) Implementation Materials located at www.ama-assn.org/ama/pub/category/1981.html. For nutritional screening for all ages, refer to Bright Futures.

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CHILDREN’S SERVICES HANDBOOK

A.3 Guidelines for Tuberculosis Skin Testing For information on procedures for tuberculosis skin testing, refer to the Department of State Health Services (DSHS) tuberculosis web page at www.dshs.state.tx.us/idcu/disease/tb/. Tuberculosis screening questionnaires can be downloaded from the Tuberculosis Elimination Division website at www.dshs.state.tx.us/idcu/disease/tb/forms/default.asp#clinic.

A.4 Laboratory Forms For information on procedures for submission of laboratory forms, refer to the DSHS Laboratory Services Section’s web page at www.dshs.state.tx.us/lab/MRS_forms.shtm.

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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.37

Child Health History (2 Pages)

Child Health History Department of State Health Services Child Health Record Preventive Health Visit Pregnancy and Birth G ___ P ___ AB ____ Total number of living children ________Weight gain/loss__________ Mother’s age at birth ________________ Number of years between previous pregnancy and this child _______ Trimester Prenatal Care Began: 1 2 3 Prenatal Care Provider _______________________________________ Vitamins: ____Y __ N Iron: ____Y __ N If child over 5 years: uncomplicated pregnancy, labor, delivery and nursery course:___ Y____N* *If yes, proceed with “Child’s Medical History.

Maternal Complications ____Vaginal bleeding ____Anemia ____Hypertension ____Rh negative ____Diabetes ____Premature labor ____Injury/hospitalization/surgery

____Flu-like illness or high temp. ____Kidney or bladder infection ____STDs ____Hepatitis (A, B, or C) ____Exposure to TB ____Exposure to lead/chemicals ____Dental disease

Maternal Substance Use ____OTC meds _____________________________________________ ____Prescription meds ______________________________________ ____Tobacco ______________________________________________ ____Alcohol ______________________________________________ ____Street drugs ___________________________________________ ____Caffeine ______________________________________________

Abbreviations for relatives listed below.

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Anemia//blood disorder Heart disease before age 50 Cholesterol req. treatment Hypertension/stroke Asthma/allergy Cancer Diabetes Epilepsy/seizures Kidney problems Muscle/bone disease Genetic disease or major birth defects ____ Childhood hearing impairment ____ Tuberculosis Explanation of positive history:

Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship: ______________________________________ Medical Home: _____________________________________________

Birth/Delivery Place of birth ______________________________________________ Birth attendant _____________________________________________ Hours of labor______________________________________________ ____Term ____Premature (Weeks)________ ____More than 2 weeks overdue Type of delivery:

PGM PGF PA PU

-

Paternal Grandmother Paternal Grandfather Paternal Aunt Paternal Uncle

Y N HIV + individual in household (do not identify) ____ Other immunosuppression ____ Dental decay ____ Alcohol/drug abuse ____ Tobacco use ____ Learning disorder ____ Mental retardation ____ Psychiatric disorder ____ Physical/sexual/emotional abuse ____ Domestic violence ____ Other

Complications:

____Breech ____Multiple birth ____Other

____Vaginal ____C-Section ____Forceps Explanation/Other:

Nursery Course Birth Weight _________

Birth Length ________

FOC _________

____Difficulty with initial breathing ____Transfusion ____Heart murmur ____Jaundice req. treatment ____Infection ____Seizures Age at discharge: _________ICN

____________ days

Newborn blood screening (date/location):

1. ________________________________________________________ 2. ________________________________________________________ ____ Normal ______ Abnormal

Newborn hearing test (in hospital):

Type of test: ____ ABR Referral made: ____Y Comments:

Family Medical History

M - Mother MGM - Maternal Grandmother F - Father MGF - Maternal Grandfather S - Sibling MA - Maternal Aunt MU - Maternal Uncle

Client Information

____OAE ____N

____Unknown

Child’s Medical History Immunizations current: ___Y ___N Dental care/sealants current: ___Y ___N ____Trauma/injuries ____Hospitalizations ____Surgery ____Medications ____Anemia ____Early childhood caries ____Hepatitis ____Strep throat ____Ear infections ____Bladder/kidney infections ____Pneumonia ____Developmental delays

__ Record unavailable

____Vision problems ____Hearing problems ____Seizures ____Environmental toxin exposure (lead, etc.) ____Allergies ____Asthma ____Eczema ____Substance use (alcohol, drug, tobacco) ____Other

Explanation:

Date: ________________ Signature/Title: __________________________________ Signature/Title ________________________________________

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CHILDREN’S SERVICES HANDBOOK

Child Health History If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________

Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-1

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Rev. 9/07

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.38

Child Health Record (Birth–1 Month) (2 Pages)

Birth–1 Month Department of State Health Services Child Health Record Preventive Health Visit Family Profile and Health Child lives with:

____ Father

Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship: ______________________________________ Medical Home: _____________________________________________

Nutrition

_____ No change in household since last visit _____ Mother _____ Other

Client Information

____ Stepparent

_____ Grandparent

Total adults living in home: _____________________________ Total children living in home: ____________________________ Primary caretaker for this child:__________________________ Relationship: _________________________________________ Family’s concerns/problems:

Problems: developmental, special diet, inappropriate weight gain/loss, chronic GI problems* _____ Y _____ N *If answered yes, further assessment needed. Breast-fed: Number of feedings in last 24 hours: _________________ Length of feedings: _________________ WIC: _____ Y _____ N Formula-fed: Type:__________________________________________ Iron fortified: _____ Y _____ N Ounces consumed in 24 hours: _______ Fluoride: _____ Y _____ N Solid foods introduced at age:

Development

Sensory

Parent’s concerns:

Developmental Screening:

_____P ____ F

Type of Developmental Screen:

Standardized Parent Questionnaire: _____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ Further assessment needed: _____Y ____ N Mental Health (see “Key Elements” on reverse side):

Child’s Health Allergies:

Does the system review note any problems or parent concerns: _____ Y _____ N Explain: Major illness, injury, hospitalization, surgery (state when and describe):

Vision Screen: Hearing Screen: Screen used:

_____Normal _____ Abnormal _____Normal _____ Abnormal _____Hearing Checklist for Parents

Health Education Injury Prevention

Health Promotion

___Car safety restraints ___Crib safety ___Burns ___Falls ___Drowning/bath safety ___911 ___Sleep position (SIDS) ___Passive smoking

___Care of skin, umbilical cord, circumcision ___Family planning ___Well-child care ___When to call doctor

Behavior

Medications taken regularly — Type/Reason:

___Crying/colic ___Sleeping ___Infant temperature

Physical Examination

Assessment

Nutrition

___Breastfeeding ___No solids until 4 months ___Formula preparation ___Infant held for bottle ___No bottle in bed

Temp _________ Pulse ____________Resp ____________ FOC__________ Height ___________Weight ___________ (%) ___________ (%) ______________(%) ______________ N

___ ___ ___ ___ ___ ___ ___ ___ ___ ___

A NE

___ ___ ___ ___ ___ ___ ___ ___ ___ ___

___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes (RR) ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts

Additional documentation:

N

___ ___ ___ ___ ___ ___

A NE

___ ___ ___ ___ ___ ___

___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine/hips ___ Extremities

Plan

Neurologic:

___ ___ ___ Muscle tone ___ ___ ___ DTRs ___ ___ ___ Primitive reflexes

WIC: __ Referred __ Refused __ N/A Immunizations: __ Up to date __ To be given today __ Deferred Explain: Lab: Newborn Screening: _____ Up to date ____ To be done today Next appointment:

Date: ________________ Signature/Title: __________________________________ Signature/Title ________________________________________

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CHILDREN’S SERVICES HANDBOOK

Birth–1 Month If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________

Key Elements Systems Review Skin: Rashes, infections, jaundice, cyanosis Ears: Hearing or ear problems Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal:

Eyes: Eye discharge, excessive tearing Nose/Mouth/Throat: Nasal congestion

History of murmur, trouble with breathing, wheezing Bowel movement frequency, problems/concerns, vomiting (Male) Normal stream, circumcision, number of wet diapers Seizures, sucking reflex, swallowing Range of motion

Mental Health The mental health assessment of this age also includes the developmental assessment and information from the family profile. Feelings: Behavior: Social Interaction: Thinking: Physical Problems: Other:

Anxious, cries excessively or too little, irritable Overactivity, listlessness Failure to respond socially Unattentive Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse

Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-2

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Rev. 1/07

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.39

Child Health Record (2–6 Months) (2 Pages) Client Information

2–6 Months Department of State Health Services Child Health Record Preventive Health Visit Family Profile and Health

Nutrition

_____ No change in household since last visit ____ Father

developmental,special diet, inappropriate _____ Y _____ N weight gain/loss, chronic GI problems* *If answered yes, further assessment needed. Breast-fed: Number of feedings in last 24 hours: _________________ WIC: _____ Y _____ N Length of feedings: _________________ Formula-fed: Type: __________________________________________ _____ Y _____ N Iron fortified: Ounces consumed in 24 hours: _______ Fluoride: _____ Y _____ N Problems:

Child lives with:

_____ Mother _____ Other

Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship:______________________________________ Medical Home: _____________________________________________

____ Stepparent

_____ Grandparent

Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child:__________________________ Relationship:_________________________________________ Family’s concerns/problems:

Solid foods introduced at age:

Development

Sensory

Parent’s concerns:

DevelopmentalScreening:

_____P ____ F

Vision Screen: Hearing Screen: Screen used:

Type of Developmental Screen:

Standardized Parent Questionnaire:_____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ _____Y ____ N Further assessment needed: Mental Health (see “Key Elements” on reverse side):

Child’s Health/Interim History Allergies:

Does the system review note any problems _____ Y _____ N or parent concerns: Explain: Major illness, injury, hospitalization,surgery (since last visit):

_____Normal _____ Abnormal _____Normal _____ Abnormal _____Hearing Checklist for Parents

Health Education Injury Prevention

Health Promotion

____Car safety restraints ____Falls, Infant walker ____Burns ____Choking management ____Sleep position (SIDS) ____Passive smoking ____Pool/bath safety

____Immunizations ____Thermometer use, Tylenol ____Teething, wipe teeth ____When to call doctor ____Well-child care ____Family planning

Behavior

____Breastfeeding ____No solids until 4 months ____Formula preparation ____Infant held (no bottlein bed)

Medications taken regularly —Type/Reason:

____Parent/infant interaction ____Sleeping ____Inappropriate expectations ____Daycare/babysitters

Physical Examination

Assessment

Nutrition

Temp _________ Pulse ____________Resp ____________ FOC __________ Length ___________Weight___________ (%)___________ (%) ______________(%)______________ N

A

____ ____ ____ ____ ____ ____ ____ ____ ____ ____

__ __ __ __ __ __ __ __ __ __

NE

___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes (RR) ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts

Additional documentation:

N

A

____ ____ ____ ____ ____ ____

__ __ __ __ __ __

NE

___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine/hips ___ Extremities

Plan

Neurologic:

____ __ ___ Muscle tone ____ __ ___ DTRs ____ __ ___ Primitive reflexes

Dental Referral ____ ____ Referred ___ N/A ____ Refused WIC: To be given today ___ Deferred Immunizations: Up to date Explain: Lab: Hct/Hgb ______ Lead questionnaire (at 6 months) ______ Newborn Screening: Up to date ____ To be done today Next appontment:

Date: ________________ Signature/Title: __________________________________ Signature/Title________________________________________

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CHILDREN’S SERVICES HANDBOOK

2–6 Months If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________

Key Elements Systems Review Skin: Ears:

Rashes, infections Hearing or ear problems

Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal:

Eyes: Eye discharge, deviation, excessive tearing Nose/Mouth/Throat: Nasal congestion

History of murmur, trouble with breathing, wheezing Bowel movementfrequency, problems/concerns, vomiting (Male) Normal stream, number of wet diapers Seizures, coordinated movements Fractures, range of motion

Mental Health The mental health assessment of this age also includes the developmentalassessment and informationfrom the family profile. Feelings: Anxious, cries excessively or too little,irritable Behavior: Overactivity,listlessness Social Interaction: Failure to respond socially Thinking: Unattentive Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse

Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

TDH-ECH-3 Rev. 01/2011

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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.40

Child Health Record (7–12 Months) (2 Pages)

Client Information

7–12 Months Department of State Health Services Child Health Record Preventive Health Visit Family Profile and Health

Nutrition

_____ No change in household since last visit Child lives with:

_____ Mother _____ Other

____ Father

Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship: ______________________________________ Medical Home: _____________________________________________

____ Stepparent

_____ Grandparent

Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child: __________________________ Relationship: _________________________________________ Family’s concerns/problems:

Problems: developmental, special diet, inappropriate weight gain/loss, chronic GI problems* _____ Y _____ N *If answered yes, further assessment needed. Breast-fed: Number of feedings in last 24 hours: _________________ Length of feedings: _________________ WIC: _____ Y _____ N Formula-fed: Type: __________________________________________ Iron fortified: _____ Y _____ N Ounces consumed in 24 hours: _______ Fluoride: _____ Y _____ N Solid foods introduced at age:

Development

Sensory

Parent’s concerns:

Developmental Screening:

_____P ____ F

Type of Developmental Screen:

Standardized Parent Questionnaire: _____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ Further assessment needed: _____Y ____ N Mental Health (see “Key Elements” on reverse side):

Child’s Health/Interim History Allergies:

Does the system review note any problems or parent concerns: _____ Y _____ N Explain: Major illness, injury, hospitalization, surgery (since last visit): Medications taken regularly — Type/Reason:

Physical Examination Temp _________ Pulse ____________Resp ____________ FOC __________ Length ___________Weight___________ (%) ___________ (%) ______________(%) ______________ N

A

___ ___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___ ___ ___ ___

NE

___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts

Additional documentation:

N

A

___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___ ___

Vision Screen: Hearing Screen: Screen used:

_____Normal _____ Abnormal _____Normal _____ Abnormal _____Hearing Checklist for Parents

Health Education Injury Prevention

Health Promotion

___Car safety restraints ___Falls (stairs, gates) ___Choking management ___Water safety/temp ___Poisoning ___Child proofing ___Passive smoking

___Immunizations ___Teething ___Cleaning teeth ___When to call doctor ___Well-child care ___Dental appointment ___Family planning

Behavior

Nutrition

___Parent/infant interaction, expectations ___Speech development ___Sleep ___Separation protest ___Daycare

___Breastfeeding support ___Introduction of solids ___No bottle in bed ___Off bottle by 1 year

Assessment

NE

___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine/hips ___ Extremities

Neurologic:

___ ___ ___ Muscle tone ___ ___ ___ DTRs

Plan

TB Risk Screen ing Tool (12 months): ___ Dental referral made: __ Y _ N WIC: __ Referred ___Refused __ N/A Immunizations: __ Up to date ___To be given today __ Deferred Explain: Lab: Newborn Screening: ___ Up to date ___To be done today Hct/Hgb _____Blood lead test (at 12 months) ________ Lead questionnaire (at 9 months) ___________ Next appointment:

Date: ________________ Signature/Title: __________________________________ Signature/Title ________________________________________

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CHILDREN’S SERVICES HANDBOOK

7–12 Months If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________

Key Elements Systems Review Skin: Rashes, infections Eyes: Eye discharge, deviation, wandering eye movement Ears: Hearing or ear problems Nose/Mouth/Throat/Teeth: Nasal congestion Cardio/respiratory: History of murmur, trouble with breathing, wheezing Gastrointestinal: Bowel movement frequency, problems/concerns, vomiting Genitourinary: (Male) Normal stream Neuromuscular: Coordination Musculoskeletal: Fractures

Mental Health The mental health assessment of this age also includes the developmental assessment and information from the family profile. Feelings: Anxious, cries excessively or too little, irritable Behavior: Overactivity, listlessness Social Interaction: Failure to respond socially Thinking: Unattentive Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse

Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

TDH-ECH-4

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Rev. 01/2011

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.41

Child Health Record (13 Months–2 Years) (2 Pages)

Client Information

13 Months–2 Years Department of State Health Services Child Health Record Preventive Health Visit

Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship:______________________________________ Medical Home: _____________________________________________

Family Pr

Nutrition

_____ No change in household since last visit

Family’s concerns/problems:

special diet, inappropriateweight gain, anemic, chronic GI problems, major food allergies, _____ Y _____ N refusal of any food group, developmental* *If answered yes, further assessment needed. Usual Servings Per Day: ____Dairy __ Formula ___Breast ___Vegetables WIC: ___ Y __ N ____Breads, cereal, rice, and pasta eggs, and dry beans ____Meat, poultry, ____Fruits

Development

Sensory

Parent’s concerns:

Vision Screen: Hearing Screen: Screen used:

Problems:

Child lives with:

_____ Mother _____ Other

____ Father

____ Stepparent

_____ Grandparent

Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child:__________________________ Relationship:_________________________________________

DevelopmentalScreening:

_____P ____ F

Type of Developmental Screen:

Standardized Parent Questionnaire:_____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ _____Y ____ N Further assessment needed: Mental Health (see “Key Elements” on reverse side):

Child’s Health/Interim History Allergies:

Does the system review note any problems _____ Y _____ N or parent concerns: Explain: Major illness, injury, hospitalization,surgery (since last visit): Medications taken regularly —Type/Reason: Dental Care:

Physical Examination

BMI (2 years) ______ Temp _________ Pulse ____________Resp ____________ FOC __________ Length ___________Weight___________ (%)___________ (%) ______________(%)______________ N

____ ____ ____ ____ ____ ____ ____ ____ ____ ____

A NE

__ __ __ __ __ __ __ __ __ __

___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes ___ Ears ___ Nose ___ Mouth/throat Teeth ___ Neck ___ Chest/breasts

Additional documentation:

N

____ ____ ____ ____ ____ ____

_____Normal _____ Abnormal _____Normal _____ Abnormal _____Hearing Checklist for Parents

Health Education Injury Prevention

____Car safety restraints ____Choking, unsafe toys ____Poisoning ____Burns ____Water safety/temp ____Supervised play ____Electrical injury ____Passive smoking

____Sibling rivalry ____Toilet training Health Promotion

____Immunizations ____Smoking in home ____Well-child care ____Dental care, appointment ____Family planning ____Daycare

Behavior

Nutrition

____Parent/infant interaction ____Social interaction ____Limit TV ____Set limits

____Healthy diet/snacks ____Iron-rich foods ____Physical activity ____Weaning ____O bottleby age 1

Assessment

A NE

__ __ __ __ __ __

___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine/hips ___ Extremities

Neurologic:

____ __ ___ Muscle tone ____ __ ___ DTRs

Plan

TB Risk Questionnaire (2 years) ______ Dental referral made: ___Y ___ N ____Referred ___ Refused ___ N/A WIC: Immunizations: ____Up to date ___ To be given today ___ Deferred Explain: Lab:

Hct/Hgb ______ Blood lead test (at 2 years) __________ Lead questionnaire: (at 15 months) _____ and (at 18 months) _____ Next appointment: Date: ________________ Signature/Title: __________________________________ Signature/Title________________________________________

CH-306 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

13 Months–2 Years If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________

Key Elements Systems Review Skin: Rashes, infections Ears: Hearing or ear problems Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal:

Eyes: Eye discharge, deviation, wandering eye movement Nose/Mouth/Throat/Teeth: Nasal congestion

History of murmur, trouble with breathing, wheezing Bowel movementfrequency Urinary frequency, (male) normal stream, dysuria, discharge Seizures, coordination, gait Fractures

Mental Health The mental health assessment of this age also includes the developmentalassessment and informationfrom the family profile. Feelings: Angry, sad, fearful, sullen, anxious, cries excessively or too little Behavior: Overactivity,listlessness, harms others, sexually acts out, refuses to talk Social Interaction: Withdrawn, clings excessively Thinking: Mistrustful, distracted, problems concentrating Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse

Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

TDH-ECH-5

CH-307 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

Rev. 01/2011

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.42

Child Health Record (3–5 Years) (2 Pages)

Client Information

3–5 Years Department of State Health Services Child Health Record Preventive Health Visit

Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship:______________________________________ Medical Home: _____________________________________________

Family Profile and Health

Nutrition

_____ No change in household since last visit

Problems: special diet, inappropriateweight gain, anemic, lead poisoning, chronic GI problems, major food allergies, refusal of any food group, developmental* _____ Y _____ N *If answered yes, further assessment needed. Usual Servings Per Day: ____Dairy __ Vegetables__ WIC: ___ Y __ N ____Breads, cereal, rice, and pasta Flouride Supplements: ___ Y __ N ____Meat, poultry, fish, eggs, and dry beans ____Fruits Vitamins: ___ Y __ N

Child lives with:

_____ Mother _____ Other

____ Father

____ Stepparent

_____ Grandparent

Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child:__________________________ Relationship:_________________________________________ Family’s concerns/problems:

Development

Sensory

Parent’s concerns:

DevelopmentalScreening:

_____P ____ F

Type of Developmental Screen:

Standardized Parent Questionnaire:_____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ Further assessment needed: _____Y ____ N Mental Health (see “Key Elements” on reverse side):

Child’s Health/Interim History Allergies:

Does the system review note any problems or parent concerns: _____ Y _____ N Explain: Major illness, injury, hospitalization,surgery (since last visit):

Dental Care:

Physical Examination

BMI__________ Temp _________ Pulse ____________Resp ____________ BP ___________ Height ___________Weight___________ (%)___________ (%) ______________(%)______________ N

A NE

__ __ __ __ __ __ __ __ __ __

___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts

Additional documentation:

N

____ ____ ____ ____ ____ ____

Health Education Injury Prevention

____Car safety restraints ____Poisoning ____Fire safety ____Firearms ____Street, water, bicycle safety ____Scissors/sharp objects ____Stranger safety ____Teach telephone no. & address ____Self-safety ____Passive smoking Behavior

Medications taken regularly —Type/Reason:

____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Vision Screen: _____Normal ____ Abnormal Hearing Screen: _____Normal ____ Abnormal Hearing Screen Used (3 years): _____ Hearing Checklist for Parents

____Talk/read with child ____Exploration ____Limit television ____Discipline, consistency

____Toilet training ____Social interaction ____School readiness ____Sex education Health Promotion

____Immunizations ____Well-child care ____Dental care, appointment ____Family planning ____Daycare Nutrition

____Healthy diet/snacks ____Junk food ____Iron-rich foods ____Physical activity

Assessment

A NE

__ __ __ __ __ __

___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine ___ Extremities

Plan

Neurologic:

____ __ ___ Muscle tone ____ __ ___ DTRs

TB Risk Screening Tool: _____ Dental referral made: ___Y

___ N

WIC: ____Referred ___ Refused ___ N/A Immunizations: ___Up to date ___ To be given today ___ Deferred Explain: Lab: Lead questionnaire: ______ Y _____ N Hct/Hgb ______ Next appointment:

Date: ________________ Signature/Title: __________________________________ Signature/Title________________________________________

CH-308 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

3–5 Years If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________

Key Elements Systems Review Skin: Rashes, infections Ears: Hearing or ear problems Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal:

Eyes: Eye discharge, blinking, tearing Nose/Mouth/Throat/Teeth: Nasal congestion

History of murmur, trouble with breathing, wheezing Bowel movementfrequency, soiling Dysuria, discharge Seizures, coordination, gait Fractures

Mental Health The mental health assessment of this age also includes the developmentalassessment and informationfrom the family profile. Feelings: Out of control, angry, sad, fearful, sullen, anxious Behavior: Overactive, listlessness, harms others or property, sexually acts out, impulsive, frequentlyprovokes other children, self-abuses Social Interaction: Withdrawn, clings excessively, acts too young, communicates non-verballyrather than verbally Thinking: Mistrustful, distracted, easily frustrated Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse

Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

TDH-ECH-6

CH-309 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

Rev. 01/2011

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.43

Child Health Record (6-10 Years) (2 Pages)

Client Information

6–10 Years Department of State Health Services Child Health Record Preventive Health Visit

Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship: ______________________________________ Medical Home: _____________________________________________

Family Profile and Health

Nutrition

_____ No change in household since last visit

Problems: special diet, inappropriate weight gain, anemic, lead poisoning, chronic GI problems, major food allergies, refusal of any food group* _____ Y _____ N *If answered yes, further assessment needed. Usual Servings Per Day: ____Dairy ____Vegetables __ Fruits ____Breads, cereal, rice, and pasta ____Meat, poultry, fish, eggs, and dry beans

Child lives with:

_____ Mother _____ Other

____ Father

____ Stepparent

_____ Grandparent

Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child: __________________________ Relationship: _________________________________________ Family’s concerns/problems:

Sensory Mental Health

Vision Screen: Hearing Screen:

(+ indicates need for futher assessment) ____Special education classes ____No/excessive extracurricular activities ____Substance abuse/use ____Self-concept problems

____Sleep Problems ____Behavior/problems ____Relationship problems with parents, siblings, peers ____Problems in school Grade Level ____________ Comments:

Child’s Health/Interim History Allergies:

Does the system review note any problems or parent concerns: _____ Y _____ N Explain: Major illness, injury, hospitalization, surgery (since last visit): Medications taken regularly — Type/Reason:

_____Normal _____Normal

____ Abnormal ____ Abnormal

Health Education Injury Prevention

____Seat belt/auto safety ____Bicycles/ATV ____Athletics ____Water safety ____Smoke detectors ____Firearm safety Behavior

____Substance abuse ____Tobacco use ____Security ____Discipline patterns ____Responsibility

____Communication/conflict resolution Health Promotion

____Limit TV viewing ____Passive smoking ____Regular exercise ____Pubertal changes/sexuality ____Dental care/sealants Nutrition

____Healthy diet/snacks ____Junk food ____Iron-rich foods

Assessment Dental Care/sealants:

Physical Examination

BMI _____________ Temp _________ Pulse ____________Resp ____________ BP ___________ Height ___________Weight___________ (%) ___________ (%) ______________(%) ______________ N

A

____ ____ ____ ____ ____ ____ ____ ____ ____ ____

__ __ __ __ __ __ __ __ __ __

NE

___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts (Tanner stage)

Additional documentation:

N

A

____ ____ ____ ____

__ __ __ __

NE

___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus (Tanner stage) ____ __ ___ Spine ____ __ ___ Extremities

Plan

Neurologic:

____ __ ___ Muscle tone ____ __ ___ DTRs TB Risk Screening Tool: _____ Dental referral made: _____ Y _____ N Immunizations: ___Up to date ___ To be given today Explain: Lab: Lead questionnaire (at 6 years): _____ Hct/Hgb ______ Next appointment:

___ Deferred

Date: ________________ Signature/Title: __________________________________ Signature/Title ________________________________________

CH-310 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

2–6 Months If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________

Key Elements Systems Review Skin: Ears:

Rashes, infections Hearing or ear problems

Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal:

Eyes: Eye discharge, deviation, excessive tearing Nose/Mouth/Throat: Nasal congestion

History of murmur, trouble with breathing, wheezing Bowel movementfrequency, problems/concerns, vomiting (Male) Normal stream, number of wet diapers Seizures, coordinated movements Fractures, range of motion

Mental Health The mental health assessment of this age also includes the developmentalassessment and informationfrom the family profile. Feelings: Anxious, cries excessively or too little,irritable Behavior: Overactivity,listlessness Social Interaction: Failure to respond socially Thinking: Unattentive Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse

Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

TDH-ECH-3 Rev. 01/2011

CH-311 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.44

Hearing Checklist for Parents

Hearing Checklist for Parents

Client Information Name: _________________________________________________________________________ DOB: ________/__________/ ________Age: ______________Sex: _______________________ SSN/Record No.:________________________________________________________________ Race/Ethnicity:__________________________________________________________________ Informant/Relationship: _________________________________________________________ Medical Home: _________________________________________________________________

Age 0 to 3 Yrs

Yes

No

0 to 3 months

❑

❑

Does your baby get quiet for a moment when you talk to him/her?

❑

❑

Does your baby act startled or stop moving for a moment when there are sudden loud noises?

❑

❑

Does your baby turn his/her eyes or head to the sound of your voice if he/she cannot see you?

❑

❑

Does your baby smile or stop crying when you or someone else he/she knows speaks?

❑

❑

Does your baby stop and pay attention when you say “no” or call his/her name?

❑

❑

Does your baby move his/her head around to try and find out where a new sound is coming from?

4 to 6 months 7 to 9 months

❑

❑

Does your baby make strings of sounds (“ba ba ba, da da da”)?

10 to 15 months ❑

❑

Does your baby give you toys or other objects (bottle) when you ask, without your having to use a gesture (holding out your hand or pointing)?

❑

❑

Does your baby point to familiar objects if you ask (“dog,” “light”)?

16 to 24 months ❑

❑

Does your child use his/her voice most of the time to get what he/she wants or to communicate with you?

❑

❑

Can your child go get familiar objects that are kept in a regular place if you ask him/her (“Get your shoes.”)?

25 to 36 months ❑

❑

Does your child answer different kinds of questions (“When...,” “Who...,” “What...,”)?

❑

❑

Does your child notice different sounds (telephone ringing, shouting, doorbell)?

If you answered “no” to any of the above questions, ask your doctor about a hearing test for your baby. Babies can be tested as soon as the day of birth.

Date of visit /

/

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/

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/

/

/

/

/

/

/

/

/

/

/

Age

Result

Signature of Provider

Department of State Health Services Publication No. EFO5-12234 8/05

CH-312 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

CH.45

Hearing Checklist for Parents (Spanish)

Lista de comprobación de audición para los padres

Información del cliente Nombre: _______________________________________________________________________ Fecha de Nac.: __________/ ________/__________________Edad:________Sexo: _________ No. de SS/Expediente: __________________________________________________________ Raza o etnicidad: _______________________________________________________________ Informante/Parentesco:__________________________________________________________ Médico personal: _______________________________________________________________

De 0 a 3 años

Sí

No

De 0 a 3 meses

❑

❑

¿Su bebé se tranquiliza por un momento cuando le habla?

❑

❑

¿Su bebé actúa sorprendido o deja de moverse por un momento cuando hay ruidos fuertes repentinos?

❑

❑

¿Su bebé dirige la mirada o gira la cabeza hacia el sonido de su voz si no la está viendo?

❑

❑

¿Su bebé sonríe o deja de llorar cuando le habla usted u otra persona que él conoce?

❑

❑

¿Su bebé deja de hacer lo que está haciendo y pone atención cuando le dice "no" o lo llama por su nombre?

❑

❑

¿Su bebé gira la cabeza hacia todos lados y trata de encontrar de dónde viene algún sonido nuevo?

De 4 a 6 meses De 7 a 9 meses

❑

❑

¿Su bebé hace sonidos repetidos ("gu-gú, da-dá")?

De 10 a 15 meses ❑

❑

¿Su bebé le da a usted juguetes u otros objetos (la botella) cuando se los pide, sin tener que usar gestos (extender la mano o señalar)?

❑

❑

¿Su bebé señala con el dedo objetos familiares si se lo pide ("el perro", "la luz")?

De 16 a 24 meses ❑

❑

¿Su hijo usa principalmente la voz para conseguir lo que quiere o cuando quiere comunicarse con usted?

❑

❑

¿Su hijo puede ir a buscar objetos familiares guardados en lugares regulares si usted se lo pide ("Vé por tus zapatos")?

De 25 a 36 meses ❑

❑

¿Su hijo responde a diferentes tipos de preguntas ("Cuándo", "Quién", "Qué")?

❑

❑

¿Su hijo distingue sonidos diferentes (el timbre del teléfono, gritos, el timbre de la puerta)?

Si contestó "No" a cualquiera de las preguntas anteriores pida a su médico un examen auditivo para su bebé. Se puede examinar a los bebés tan pronto como el día de su nacimiento. Fecha de la visita Edad

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

Resultado

Firma del proveedor

Departamento de servicios médicos estatales Publicacién No. EFO5-12234 8/05

CH-313 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.46

Mental Health Interview Tool/Referral Form (Ages 0–2 Years)

Mental Health Interview Tool/Referral Form (Ages 0–2 Years) Mental Health Interview Tool/Referral Form

Child’s Name: ____________________________ Birth Date: _______________________________

Ages 0 to 2

Date: ____________________________________

For this age group you will obtain information from the parent/caregiver and from your own observations of the child. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation. Feelings: Does your child display feelings that concern you or seem out of the ordinary?

Behavior: Does your child display behavior that concerns you or seems out of the ordinary for his/ her age?

Social Interaction: Do you have concerns about how your child gets along with you? Other family members or adults? Siblings?

Thinking: Do you think your child’s development is normal for age?

Physical Problems: Do you have any concerns about your child’s physical health? If physical problems exist, have they been medically evaluated?

Infants

1 to 2 Years

❏

Anxious

❏

Irritable

❏

Sullen

❏

Cries excessively

❏

Angry

❏

Anxious

❏

Cries too little

❏

Sad

❏

Cries excessively

❏

Fearful

❏

Cries too little

Infants

1 to 2 Years

❏

Overactive

❏

Overactive

❏

Listlessness

❏

Listlessness

❏

Harms others

❏

Frequent temper tantrums

Infants

1 to 2 Years

❏

No eye contact or smile

❏

* No eye contact or smile

❏

Stiffens and arches

❏

Clings excessively

❏

Not responsive

❏

Not responsive

❏

Language delay

Infants (> 8 months)

1 to 2 Year

❏

❏

Mistrustful

❏

Problems concentrating or paying attention

No communication skills (pointing to request an object) or efforts to make words

Infants to 2 Years ❏

Low weight or weight loss

❏

Frequent vomiting

❏

Eating problem (poor appetite, eats nonfoods)

❏

Sleeping problem (frequent night waking)

❏

Lethargic

Other: Are there any situations which are causing your family particular stress at this time? Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what form, when, treatment initiated, etc.? Did the mother of this child use drugs or drink alcohol during the pregnancy? Comments:

Signature/Title: _______________________________________________________________________________________

CH-314 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

CH.47

Mental Health Interview Tool/Referral Form (Ages 3–9 Years)

Mental Health Interview Tool/Referral Form (Ages 3–9 Years) Mental Health Interview Tool/Referral Form

Child’s Name: ____________________________ Birth Date: _______________________________ Date: _____________________________________

Ages 3 to 9

For this age group you will obtain information from the parent/caregiver and from your own observations of the child’s behavior. If possible, interview the parent alone when asking questions about sexual or physical abuse. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation. Feelings: Behavior: Does your child display feelings that concern you or seem out of Does your child frequently display behavior that seems out of the the ordinary for age? ordinary for age? ❏ ❏ ❏ ❏ ❏ ❏ ❏

Restless Sad or cries easily Excessively guilty Lack of remorse Irritable, angers or temper tantrums easily Sullen Fearful or anxious

❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏

Problems in school * Harms other children or animals Lacks interest in things s/he used to enjoy Engages in sexual play with others, toys, animals * Destroys possessions or other property Steals Refuses to talk * Sets fires Overactive * Self-destructive * Has been in trouble with the police (older child)

Social Interaction: Thinking: Do you have concerns about how child gets along with you, other Have you noticed any of the following to be a problem for your child? family members, playmates, other adults? ❏ Withdraws including no eye contact ❏ * Frequently confused ❏ Clings excessively ❏ Daydreams excessively ❏ Difficulty making and keeping friends ❏ Distracted, doesn’t pay attention ❏ Defiant, a discipline problem ❏ * Bizarre thoughts ❏ Severe or frequent tantrums ❏ Mistrustful ❏

Aggressive

❏

❏ ❏

Argues excessively Refuses to go to school

❏ ❏

* Sees or hears things that are not there (excluding imaginary friends in younger children) Blames others for his/her misdeeds or thoughts * Talks about death

❏

Prefers to be alone

❏ ❏

* Frequent memory loss Schoolwork is slipping (grades going down)

Physical Problems: Do you have any concerns about the following physical signs? Has this been evaluated? ❏ Daytime wetting ❏ Soils pants ❏ Refusal to eat ❏ Headaches ❏ Excessive weight loss or gain ❏ Sleep problems, nightmares, sleep-walking, early waking ❏ Vomits frequently ❏ Frequent stomachaches ❏ Lacks energy

Other: Is this child accident-prone? Are there any situations that are causing your family particular stress? Has this child or his/her parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc. * Is this child at risk for out-of-home placement because of behavior problems?

Comments:

Signature/Title: _____________________________________________________________________________

CH-315 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.48

Mental Health Interview Tool/Referral Form (Ages 10–12 Years)

Mental Health Interview Tool/Referral Form (Ages 10–12 Years) Mental Health Interview Tool/Referral Form

Child’s Name: ____________________________ Birth Date: _______________________________

Ages 10 to 12

Date: _____________________________________

Both child and parent will be able to provide information, and it is important to incorporate the child into the interview process. In each section, a sample question is directed toward the parent. To the extent possible, elicit the child’s perception of the parent’s response with a question such as “Do you agree with what your Mom is saying?” It may be useful to allow time for discussion with the caregiver alone. The child should be interviewed alone when asking questions about sexual or physical abuse and about substance abuse. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation.. Feelings: Behavior: Does your child (do you) have feelings that concern you or seem Does your child (do you) behave in ways that seems out of the out of the ordinary for age? ordinary for age? ❏ Restless ❏ Problems in school ❏ Sad or cries easily ❏ * Threatens or harms other children or animals ❏ Guilty ❏ Lacks interest in things s/he used to enjoy ❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals ❏ Sullen ❏ * Destroys possessions or other property ❏ Fearful or anxious ❏ Steals ❏ Bored ❏ Refuses to talk ❏ * Sets fires ❏ Overactive ❏ * Has been in trouble with the police ❏ * Self-destructive Social Interaction: Thinking: Do you have concerns about how your child (you) gets along with Have you noticed any of the following to be a problem for your child family members, other adults or children? (you)? ❏ Prefers to be alone ❏ * Frequently confused ❏ Difficulty making and keeping friends ❏ Daydreams excessively ❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention ❏ Aggressive ❏ Mistrustful ❏ Argues excessively ❏ * Sees or hears things that are not there ❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts ❏ * Talks about death or suicide ❏ * Frequent memory loss ❏ * Bizarre thoughts ❏ Schoolwork is slipping (grades going down) Physical Problems: Do you have any concerns about the following physical signs? Has this been evaluated? ❏ Lacks energy ❏ Uses laxatives ❏ Vomits frequently ❏ Food refusal, secretive eating ❏ Frequent stomachaches ❏ Headaches ❏ Excessive weight loss or gain ❏ Sleep problems, nightmares, sleep-walking, early waking, frequent night waking

Other: Is this child (are you) accident-prone? Are there any situations that are causing your family particular stress? Has this child or his/her parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc. ❏

* Is this child at risk for out-of-home placement because of behavior problems?

❏

Has the child (have you) been treated for mental health problems or substance abuse?

Substance Abuse Questions: (May want to use screens such as the TACE, CAGE, MAST to obtain information concerning substance abuse.) ❏ Has been identified as a problem

Comments:

Signature/Title: _____________________________________________________________________________

CH-316 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

CH.49

Mental Health Interview Tool/Referral Form (Ages 13–20 Years)

Mental Health Interview Tool/Referral Form (Ages 13–20 Years) Mental Health Interview Tool/Referral Form

Child’s Name: ____________________________ Birth Date: _______________________________

Ages 13 to 20

Date: _____________________________________

You may begin with a joint interview or begin with separate interviews with the parent/caregiver and adolescent. It is preferable to interview the adolescent first. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation. Feelings: Behavior: Do you (does your teen) have feelings that concern you or seem Do you (does your child) behave in ways that seems out of the out of the ordinary for (their) age? ordinary for your (their) age? ❏ Restless ❏ Problems at school or work ❏ Sad or cries easily ❏ * Threatens or harms other children or animals ❏ Guilty ❏ Lacks interest in things s/he used to enjoy ❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals ❏ Sullen ❏ * Destroys possessions or other property ❏ Fearful or anxious ❏ Steals ❏ Bored ❏ Refuses to talk ❏ * Sets fires ❏ Overactive ❏ * Has been in trouble with the police ❏ * Self-destructive Social Interaction: Thinking: Do you have concerns about how (you) your child gets along with Have you noticed any of the following to be a problem for you (your family members, other adults, or peers? child)? ❏ Prefers to be alone ❏ * Frequently confused ❏ Difficulty making and keeping friends ❏ Daydreams excessively ❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention ❏ Aggressive ❏ Mistrustful ❏ Argues excessively ❏ * Sees or hears things that are not there ❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts ❏ * Talks about death or suicide ❏ * Frequent memory loss ❏ * Bizarre thoughts ❏ Schoolwork is slipping (grades going down) Physical Problems: Do you have any concerns about the following physical signs? Has this been evaluated? ❏ Lacks energy ❏ Uses laxatives ❏ ❏ ❏ ❏ ❏ ❏

Vomits frequently Food refusal, secretive eating Frequent stomachaches Headaches Excessive weight loss or gain Sleep problems, nightmares, sleep-walking, early waking, frequent night waking

Other: Are you (is this child) accident-prone? Are there any situations that are causing your family particular stress? Have you (has this child) or your (his/her) parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc. ❏ * Are you (is this child) at risk for out-of-home placement because of behavior problems? ❏

Have you (has this child) been treated for mental health problems or substance abuse?

Substance Abuse Questions: (May want to use screens such as the TACE, CAGE, MAST to obtain information concerning substance abuse.) ❏ Has been identified as a problem

Comments:

Signature/Title: ____________________________________________________________________________

CH-317 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.50

Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages)

Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages) Mental Health Parent Questionnaire

Child’s Name: ____________________________ Birth Date: _______________________________ Today’s Date: ____________________________

Ages Birth to 2 Years

To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned please let us know. F e e l i n g s

Does your child show feelings that concern you or seem strange for their age? ❑ Yes ❑ No

B e h a v i o r

Does your child do things that concern you or seem strange for their age? ❑ Yes ❑ No

S o c i a l

I n t e r a c t i o n

Infants

1 to 2 Years

❑ Fearful

❑ Is irritable

❑ Fearful

❑ Cries too much

❑ Is angry

❑ Cries too little

❑ Cries too little

❑ Is sad

❑ Cries too much

❑ Is sullen

Infants

1 to 2 Years

❑ Is overactive

❑ Is overactive

❑ Harms others

❑ Is listless (has little energy)

❑ Is listless (has little energy)

❑ Has temper tantrums often

Do you have any concerns about how your child gets along with you? ❑ Yes ❑ No With other family members or adults? ❑ Yes ❑ No With brothers and sisters? ❑ Yes ❑ No Infants

1 to 2 Years

❑ Does not make eye contact or smile

❑ Does not make eye contact

❑ Does not respond to you

❑ Stiffens and arches back

or smile ❑ Clings to you too much

❑ Does not say any words yet

❑ Does not respond to you

T Do you think your child is as bright and thinks as clearly as others their age? ❑ Yes ❑ No h Infants 1 to 2 Years i n ❑ Does not trust others k ❑ (>8 months) Does not point to or ask for things or try to make words ❑ Has problems concentrating or paying attention i n g

CH-318 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

P h y s i c a l

P r o b l e m s

Do you have any concerns about these things? ❑ Yes ❑ No If you think your child may have a health problem, has he/she seen a doctor or nurse about the problem? ❑ Yes ❑ No Infants to 2 Years ❑ Is low weight or has a lot of weight

❑ Has sleeping problems (wakes a lot at night)

❑ Vomits (throws up) often

❑ Has little energy

❑ Has eating problems

(poor appetite, eats non-foods)

O t h e r

Is anything causing your family stress right now? ❑ Yes ❑ No Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No Treatment initiated? ❑ Yes ❑ No Did the mother of this child use drugs or alcohol during the pregnancy? ❑ Yes ❑ No

Comments: (Please write anything else you want us to know about in this space.)

Date: ____________

Signature: ______________________________________________________ Relation to patient: _______________________________________________

CH-319 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.51

Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish)

Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish) Cuestionario de la Salud Mental para los Padres

Nombre del Niño:________________________________ Fecha de Nacimiento: ___________________________ Fecha: _________________________________________

De Recién Nacido a 2 Años de Edad Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica que tenga su bebé. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su bebé. Favor de marcar todas las características abajo que son ciertas para su bebé. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos.

S E N T I M I E N T O S

¿Tiene su bebé sentimientos que le preocupan o tal vez parezcan extraños para su edad?

C O M P O R T A M I E N T O

¿Hace su bebé cosas que le preocupan o que parezcan extrañas para su edad?

I N T E R A C C I O N E S

Bebés

P E N S A M I E N T O S

❏ No

De 1 a 2 Años

❏ Siente miedo ❏ Llora mucho ❏ Llora muy poco

❏ ❏ ❏ ❏

Es de mal carácter Es enojón Es triste

❏ Siente miedo ❏ Llora muy poco ❏ Llora mucho

Es malhumorado ❏ Sí

❏ No

¿Se preocupa sobre cómo se lleva su bebé con usted? ¿Con otros miembros de la familia o adultos?

❏ Sí ❏ Sí

❏ No ❏ No

¿Con sus hermanos o hermanas?

❏ Sí

❏ No

Bebés

De 1 a 2 Años

❏ Es demasiado activo ❏ Es indiferente (tiene poca energía)

S O C I A L E S

❏ Sí

Bebés

❏ ❏ ❏ ❏

Es demasiado activo Es indiferente (tiene poca energía) Lastima a otros Hace berrinches frecuentemente

De 1 a 2 Años

❏ No ve a los ojos ni sonríe ❏ Se pone tieso y se dobla arqueando la espalda ❏ No le responde

❏ ❏ ❏ ❏

No ve a los ojos ni sonríe La mayoría del tiempo no se le despega No le responde Todavía no dice ninguna palabra

¿Piensa usted que su nino es tan inteligente y que piensa tan claramente como otros niños de su edad?

Bebés

❏ Sí

❏ No

De 1 a 2 Años

❏ (>8 meses) No pide ni senala a las cosas o trata de decir palabras

❏ No le tiene confianza a otros ❏ Tiene problemas para concentrarse y poner atención

CH-320 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

¿Se preocupa usted sobre los siguientes problemas físicos? Si usted piensa que su niño tiene un problema de salud, ¿Lo ha llevado a consultar con un médico o una enfermera debido a ese problema?

P R O B L E M A S

F I S I C O S

❏ No

❏ Sí

❏ No

De recién nacidos a 2 Años ❏ Es de peso bajo o ha perdido mucho peso ❏ Se vomita frecuentemente ❏ Tiene problemas para comer (muy poco

apetito, come alimentos que no son saludables)

O T R O S

❏ Sí

❏ Tiene problemas para dormir (se despierta mucho durante la noche)

❏ Tiene muy poca energía

¿Hay algo que le esté causando tensión a su familia ahora?

❏ Sí

❏ No

¿Ha estado este niño o sus padres sujetos a la negligencia o al abuso físicos, sexual o emocional? Si sí, ¿en qué forma?_____________________ ¿Cuándo?_____________ ¿Empezó el tratamiento?

❏ Sí ❏ No ❏ Sí ❏ No

¿Usó drogas o tomó bebidas alcohólicas durante su embarazo la mamá de este niño?

❏ Sí ❏ No

Comentarios: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)

Fecha:_____________ Firma:________________________________________________________________ Parentesco con el paciente:_____________________________________________

CH-321 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.52

Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages)

Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) Mental Health Parent Questionnaire

Child’s Name: ____________________________ Birth Date: _______________________________

Ages 3 to 9 Years

Today’s Date: ____________________________

To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned please let us know. F e e l i n g s

Does your child show feelings that concern you or seem strange for their age? ❑ Yes ❑ No

B e h a v i o r

Does your child do things that seem strange for their age? ❑ Yes ❑ No

S o c i a l

I n t e r a c t i o n

T h i n k i n g

❑ Is restless

❑ Is irritable, angers or temper tantrums easily

❑ Is sad or cries easily

❑ Is sullen

❑ Is overly guilty

❑ Fearful

❑ Lacks remorse

❑ Has problems in school

❑ Refuses to talk

❑ Harms other children or animals

❑ Sets fires

❑ Lacks interest in things s/he used to enjoy

❑ Is over-active

❑ Plays sexual games with others, toys, animals

❑ Hurts himself or herself

❑ Destroys possessions or other property

❑ Has been in trouble with the police

❑ Steals

Do you have any concerns about how your child gets along with you? ❑ Yes ❑ No With other family members or adults? ❑ Yes ❑ No ❑ No With playmates? ❑ Yes ❑ Withdraws and does not look into peoples’ eyes

❑ Picks on others a lot or often gets into fights (hitting, etc.)

❑ Clings to you too much

❑ Argues too much

❑ Has a hard time making and keeping friends

❑ Will not go to school

❑ Is defiant, has a disciplinary problem

❑ Prefers to be alone

❑ Severe or frequent tantrums

Are any of these a problem for your child? ❑ Yes ❑ No ❑ Is frequently confused (does not understand what is going on) ❑ Daydreams a lot ❑ Is distracted, doesn’t pay attention ❑ Has very strange thoughts ❑ Schoolwork is slipping (grades going down)

❑ Does not trust others ❑ Sees or hears things that are not there ❑ Blames others for his/her misdeeds or thoughts ❑ Talks about death a lot ❑ Often cannot remember things

CH-322 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

Do you have any concerns about these things? ❑ Yes ❑ No If you think your child may have a health problem, has he/she seen a doctor or nurse about the problem? ❑ Yes ❑ No

P h y s i c a l

P r o b l e m s

O t h e r

Is this child accident-prone? ❑ Yes ❑ No Is anything causing your family stress right now? ❑ Yes ❑ No Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No Treatment initiated? ❑ Yes ❑ No Is this child at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No

❑ Has daytime wetting

❑ Has sleeping problems, nightmares, sleep-walking, early waking

❑ Soils pants

❑ Vomits (throws up) often

❑ Will not eat

❑ Has stomach aches often

❑ Has headaches

❑ Lacks energy

❑ Has lost or gained a lot of weight

Comments: (Please write anything else you want us to know about in this space.)

Date: ____________

Signature: ______________________________________________________ Relation to patient: _______________________________________________

CH-323 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.53

Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish)

Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish) Cuestionario de la Salud Mental para los Padres De 3 a 9 Años de Edad

Nombre del Niño:________________________________ Fecha de Nacimiento: ____________________________ Fecha: _________________________________________

Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica que tenga su niño. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su niño. Favor de marcar todas las características abajo que sean ciertas para su niño. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos.

S E N T I M I E N T O S

¿Tiene su niño sentimientos que le preocupan o tal vez parezcan extraños para su edad?

C O M P O R T A M I E N T O

¿Hace su niño cosas que le parezcan extrañas para su edad?

I N T E R A C C I O N E S

❏ ❏ ❏ ❏

❏ Sí

❏ No

❏ Es de mal carácter, enojón o hace berrinches

Es inquieto Es triste o llora fácilmente Se siente muy culpable No tiene remordimiento

temperamentales fácilmente

❏ Es malhumorado ❏ Siente miedo

❏ Sí

❏ No

¿Se preocupa sobre cómo se lleva su niño con usted? ¿Con otros miembros de la familia o adultos?

❏ Sí ❏ Sí

❏ No ❏ No

¿Con sus compañeros de juego?

❏ Sí

❏ No

❏ ❏ ❏ ❏

Tiene problemas en la escuela Lastima a otros niños o a los animales No le interesan las cosas que antes le gustaban Juega juegos sexuales con otros niños, juguetes, o animales

❏ ❏ ❏ ❏ ❏

Se niega a hablar Provoca incendios Es demasiado activo Se lastima Ha tenido problemas con la policía

❏ Destruye cosas personales u ajenas ❏ Roba

S O C I A L E S

❏ ❏ ❏ ❏ ❏

Se aleja y no ve a nadie a los ojos La mayoría del tiempo no se le despega Se le dificulta hacer y mantener amistades Es desafiante, tiene un problema de disciplina Hace berrinches tempermentales fuertes o

❏ Siempre molesta a otros o frecuentemente se pelea (pegando, etc.)

❏ Discute mucho ❏ No quiere asistir a la escuela ❏ Prefiere estar solo

frecuentemente

❏ Sí

¿Son algunas de estas características un problema para su niño? P E N S A M I E N T O S

❏ Se confunde frecuentemente (no entiende lo que está pasando)

❏ ❏ ❏ ❏

Sueña mucho despierto Se distrae, no pone atención Tiene pensamientos muy extraños Se está atrasando en el trabajo de la escuela (sus grados están bajando)

❏ No

❏ No le tiene confianza a los demás ❏ Mira u oye cosas que no están allí ❏ Culpa a otros por algo que hizo mal o por sus pensamientos

❏ Habla mucho sobre la muerte ❏ Frecuentemente no se acuerda de cosas

CH-324 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

P R O B L E M A S

F I S I C O S

O T R O S

¿Se preocupa usted sobre los siguientes problemas físicos? Si usted piensa que su niño tiene un problema de salud, ¿Lo ha llevado a consultar con un médico o una enfermera debido a ese problema?

❏ ❏ ❏ ❏ ❏

Se orina durante el día Ensucia sus pantalones No quiere comer Tiene dolores de cabeza Ha perdido o aumentado mucho de peso

❏

❏ Sí

❏ No

❏ Sí

❏ No

Tiene problemas para dormir, pesadillas, se despierta temprano y sonámbulo

❏ Se vomita frecuentemente ❏ Tiene dolores de estómago frecuentemente ❏ No tiene energía

¿Es propenso este niño a tener accidentes? ¿Hay algo que le está causando tensión a su familia ahora? ¿Ha estado este niño o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional?

❏ Sí ❏ Sí

❏ No ❏ No

Si sí, ¿en qué forma?_________________

❏ Sí

❏ No

¿Cuándo? ___________ ¿Empezó el tratamiento?

❏ Sí

❏ No

¿Corre el riesgo este niño de ser llevado a otro lugar fuera de su familia por problemas de comportamiento?

❏ Sí

❏ No

Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)

Fecha:_____________ Firma:________________________________________________________________ Parentesco con el paciente:_____________________________________________

CH-325 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.54

Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages)

Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) Mental Health Parent Questionnaire

Child’s Name: _____________________________ Birth Date: ________________________________

Ages 10 to 12 Years

Today’s Date: _____________________________

To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned please let us know. F e e l i n g s

Does your child (do you) show feelings that concern you or seem strange for their (your) age? ❑ Yes ❑ No

B e h a v i o r

Does your child (do you) often do things that seem strange for their (your) age? ❑ Yes ❑ No

S o c i a l

I n t e r a c t i o n

T h i n k i n g

Are any of these a problem for your child (you)? ❑ Yes ❑ No

❑ Is restless

❑ Is sullen

❑ Is sad or cries easily

❑ Is fearful

❑ Is guilty

❑ Is bored

❑ Is irritable or angers easily

❑ Has problems in school

❑ Refuses to talk

❑ Threatens or harms other children or animals

❑ Sets fires

❑ Lacks interest in things s/he used to enjoy

❑ Is overactive

❑ Is involved in sexual activity

❑ Hurts himself or herself

❑ Destroys possessions or other property

❑ Has been in trouble with the police

❑ Steals

Do you have any concerns about how your child (you) get(s) along with family members? ❑ Yes ❑ No ❑ No With other adults? ❑ Yes With other children? ❑ Yes ❑ No ❑ Prefers to be alone

❑ Picks on others a lot or often gets into fights (hitting, etc.)

❑ Has a hard time making and keeping friends

❑ Argues too much

❑ Is defiant, a disciplinary problem

❑ Will not go to school

❑ Is frequently confused (does not understand what is

❑ Does not trust others

going on) ❑ Daydreams a lot ❑ Is distracted, doesn’t pay attention ❑ Has very strange thoughts ❑ Schoolwork is slipping (grades going down)

❑ Sees or hears things that are not there ❑ Blames others for his/her misdeeds or thoughts ❑ Talks about death or suicide a lot ❑ Often cannot remember things

CH-326 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

Do you have any concerns about these things? ❑ Yes ❑ No If you think your child (you) may have a health problem, has he/she (have you) seen a doctor or nurse about the ❑ No problem? ❑ Yes

P h y s i c a l

P r o b l e m s

O t h e r

Is your child (you) accident-prone? ❑ Yes ❑ No Is anything causing your family stress right now? ❑ Yes ❑ No Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No Treatment initiated? ❑ Yes ❑ No Is this child (are you) at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No Does your child (do you) drink of use drugs (including street or over-the-counter)? ❑ Yes ❑ No Has this child (have you) been treated for mental health problems or substance abuse? ❑ Yes ❑ No

❑ Lacks energy

❑ Has headaches

❑ Uses laxatives

❑ Has lost or gained a lot of weight

❑ Vomits (throws up) often

❑ Has sleeping problems, nightmares, sleep-walking, early waking,

❑ Won’t eat in front of people, sneaks food

frequent night waking

later ❑ Has stomach aches often

Comments: (Please write anything else you want us to know about in this space.)

Date: ____________

Signature: ______________________________________________________ Relation to patient: _______________________________________________

CH-327 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.55

Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish)

Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish) Cuestionario de la Salud Mental para los Padres De 10 a 12 Años de Edad

Nombre del Niño:_________________________________ Fecha de Nacimiento: ____________________________ Fecha: _________________________________________

Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica que tenga su hijo. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su niño. Favor de marcar todas las características abajo que son ciertas para su niño. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos. ¿Tiene su niño sentimientos que le preocupan o tal vez parezcan extraños para su edad? S E N T I M I E N T O S

❏ ❏ ❏ ❏

C O M P O R T A M I E N T O

I N T E R A C C I O N E S

Es triste o llora fácilmente Se siente culpable

❏ Sí

❏ No

Es de mal carácter o se enoja fácilmente

❏ Tiene problemas en la escuela ❏ Amenaza o lastima a otros niños o a los animales

❏ ❏ ❏ ❏

❏ No

❏ Es malhumorado ❏ Siente miedo ❏ Se aburre

¿Hace su niño cosas que le parezcan extrañas para su edad?

S O C I A L E S

P E N S A M I E N T O S

Es inquieto

❏ Sí

No le interesan las cosas que antes le gustaban Participa en actividades sexuales

❏ ❏ ❏ ❏ ❏

Se niega a hablar Provoca incendios Es demasiado activo Se lastima Ha tenido problemas con la policía

Destruye cosas personales o ajenas Roba

¿Se preocupa sobre cómo se lleva su niño con usted? ¿Con otros adultos? ¿Con otros niños? ❏ Prefiere estar solo

❏ Se le dificulta hacer y mantener amistades ❏ Es desafiante, tiene un problema de disciplina

¿Son algunas de estas características un problema para su niño? ❏ Se confunde frecuentemente (no entiende lo que está pasando) ❏ Sueña mucho despierto

❏ Sí ❏ Sí ❏ Sí

❏

❏ No ❏ No ❏ No Siempre molesta a otros o frecuentemente se pelea (pegando, etc.) Discute mucho

❏ ❏ No quiere asistir a la escuela

❏ Sí

❏ No

❏ No le tiene confianza a los demás

❏ Se distrae, no pone atención

❏ Mira u oye cosas que no están allí ❏ Culpa a otros por algo que hizo mal o por sus

❏ Tiene pensamientos muy extraños ❏ Se está atrasando en el trabajo de la escuela (sus

❏ Habla mucho sobre la muerte o del suicidio ❏ Frecuentemente no se acuerda de cosas

grados están bajando)

pensamientos

CH-328 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

P R O B L E M A S

F I S I C O S

¿Se preocupa usted sobre los siguientes problemas físicos? Si piensa que su niño tiene un problema de salud, ¿ha ido a consultar con un médico o una enfermera debido a ese problema? ❏ La falta energía

❏ Usa laxantes ❏ Se vomita frecuentemente

❏ Sí ❏ Sí

❏ No ❏ No

❏ Tiene dolores de cabeza ❏ Ha perdido o aumentado mucho peso ❏ Tiene problemas para dormir, pesadillas, sonambulismo, despierta temprano, despierta seguido por la noche

❏ No come delante de la gente, come después a escondidas

❏ Tiene dolores de estómago frecuentemente

O T R O S

¿Es propenso a tener accidentes su niño? ¿Hay algo que le está causando tensión a su familia ahora? ¿Ha sido este niño o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional? Si sí, ¿en qué forma?_________________ ¿Cuándo? ___________ ¿Empezó el tratamiento? ¿Corre este niño el riesgo de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ¿Toma bebidas alcohólicas o usa drogas su niño (incluyendo las de la calle y las que se venden sin receta)? ¿Ha recibido su niño tratamiento por problemas de la salud mental o por el abuso de sustancia como las drogas y bebidas alcohólicas?

❏ Sí ❏ Sí

❏ No ❏ No

❏ Sí ❏ Sí ❏ Sí ❏ Sí ❏ Sí

❏ ❏ ❏ ❏ ❏

No No No No No

Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)

Fecha:_____________ Firma:________________________________________________________________ Parentesco con el paciente:_____________________________________________

CH-329 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.56

Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages)

Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) Mental Health Parent Questionnaire

Teen’s Name: ____________________________ Birth Date: _______________________________

Ages 13 to 20 Years

Today’s Date: ____________________________

To the Teen or Parent: If you will assist us by filling out this form, we can help you find your (your teen’s) strengths and any problem areas, too. Your answers will help us to know if we need to talk with you (your teen) and find out more about you (your teen). Please check all items below that are true for you (your teen). Some of the behaviors noted may be normal but if you are concerned please let us know. F e e l i n g s

Do you (does your teen) show feelings that concern you or seem strange for your (their) age? ❑ Yes ❑ No

B e h a v i o r

Do you (does your teen) often do things that seem strange for your (their) age? ❑ Yes ❑ No

S o c i a l

I n t e r a c t i o n

T h i n k i n g

Are any of these a problem for you (your teen)? ❑ Yes ❑ No

❑Restless

❑ Sullen

❑Sad or cry easily

❑ Fearful

❑Guilty

❑ Bored

❑ Irritable or angered easily

❑ Have problems in school or work

❑ Refuse to talk

❑ Threaten or harm other children or animals

❑ Set fires

❑ Lack interest in things you used to enjoy

❑ Over-active

❑ Is involved in sexual activity

❑ Hurt yourself

❑ Destroy possessions or other property

❑ Have been in trouble with the police

❑ Steal

Do you have any concerns about how you (your teen) get(s) along with family members? ❑ Yes ❑ No With other adults? ❑ Yes ❑ No With peers? ❑ Yes ❑ No ❑ Prefer to be alone

❑ Pick on others a lot or often get into fights (hitting, etc.)

❑ Have a hard time making and keeping friends

❑ Argue too much

❑ Defiant, a disciplinary problem

❑ Will not go to school

❑ Frequently confused (does not understand what is going

❑ Do not trust others

on) ❑ Daydream a lot ❑ Distracted, do not pay attention ❑ Have very strange thoughts ❑ Schoolwork is slipping (grades going down)

❑ See or hear things that are not there ❑ Blame others for your misdeeds or thoughts ❑ Talk about death or suicide a lot ❑ Often cannot remember things

CH-330 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

Do you have any concerns about these things? ❑ Yes ❑ No If you think you (your teen) may have a health problem, have you (has he/she) seen a doctor or nurse about the problem? ❑ Yes ❑ No

P h y s i c a l

P r o b l e m s

O t h e r

Are you (is your teen) accident-prone? ❑ Yes ❑ No Is anything causing your family stress right now? ❑ Yes ❑ No Have you (has your teen) or your parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No Treatment initiated? ❑ Yes ❑ No Are you (is this teen) at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No Do you (does your child) drink of use drugs (including street or over-the-counter)? ❑ Yes ❑ No Have you (has this teen) been treated for mental health problems or substance abuse? ❑ Yes ❑ No

❑ Lack energy

❑ Have headaches

❑ Use laxatives

❑ Have lost or gained a lot of weight

❑ Vomit (throw up) often

❑ Have sleeping problems, nightmares, sleep-walking, early waking,

❑ Won’t eat in front of people, sneak food

frequent night waking

later ❑ Have stomachaches often

Comments: (Please write anything else you want us to know about in this space.)

Date: ____________

Signature: ______________________________________________________ Relation to patient: _______________________________________________

CH-331 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

CH.57

Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish)

Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish) Cuestionario de la Salud Mental para los Padres De 13 a 20 Años de Edad

Nombre del Adolescente:__________________________ Fecha de Nacimiento: ____________________________ Fecha: _________________________________________

Para los Padres: Si nos ayuda llenando este formulario, podremos ayudarle a encontrar las áreas fuertes que tenga su hijo y también cualquier área problématica. Sus respuestas nos ayudarán a saber si necesitamos hablar con su hijo y saber más sobre él. Favor de marcar todas las características abajo que son ciertas para su hijo. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos. S E N T I M I E N T O S

¿Tiene su hijo sentimientos que le preocupan o tal vez parezcan extraños para su edad? ❏ Es inquieto

C O M P O R T A M I E N T O

¿Hace su hijo cosas frecuentemente que le parezcan extrañas para su edad? ❏ Tiene problemas en la escuela o en el trabajo

I N T E R A C C I O N E S

❏ Es triste o llora fácilmente ❏ Se siente culpable ❏ Es irrita o enoja fácilmente

❏ ❏ ❏ ❏ ❏

S O C I A L E S

P E N S A M I E N T O S

Amenaza o lastima a otros niños o a los animales No le interesan las cosas que antes le gustaban Está envuelto en actividades sexuales Destruye cosas personales u otras cosas ajenas

❏ Sí

❏ No

❏ Es malhumorado ❏ Siente miedo ❏ Se aburre

❏ Sí

❏ ❏ ❏ ❏ ❏

❏ No Se niega a hablar Provoca incendios Es demasiado activo Se lastima Ha tenido problemas con la policía

Roba

¿Le preocupa cómo se lleva su hijo con los miembros de la familia? ¿Con otros adultos? ¿Con su grupo social? ❏ Prefiere estar solo

❏ Se le dificulta hacer y mantener amistades ❏ Es desafiante, tiene un problema de disciplina

¿Son algunas de estas características un problema para su hijo? ❏ Se confunde frecuentemente (no entiende lo que está pasando) ❏ Sueña mucho despierto

❏ Sí

❏ No

❏ Sí ❏ Sí

❏ No ❏ No Molesta mucho a otros o frecuentemente se pelea (pegando, etc.) Discute mucho

❏

❏ ❏ No quiere asistir a la escuela

❏ Sí

❏ No

❏ No le tiene confianza a los demás

❏ Se distrae, no pone atención

❏ Mira u oye cosas que no están allí ❏ Culpa a otros por algo que hizo mal o por sus

❏ Tiene pensamientos muy extraños ❏ Se está atrasando en el trabajo de la escuela (sus

❏ Habla mucho sobre la muerte o el suicidio ❏ Frecuentemente no se acuerda de cosas

grados están bajando)

pensamientos

CH-332 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK

P R O B L E M A S

F I S I C O S

¿Se preocupa por estas cosas? Si piensa que su hijo tiene un problema de salud, ¿ha ido a consultar con un médico o una enfermera por este problema? ❏ No tiene energía

❏ Usa laxantes ❏ Se vomita frecuentemente

❏ Sí ❏ Sí

❏ No ❏ No

❏ Tiene dolores de cabeza ❏ Ha perdido o aumentado mucho peso ❏ Tiene problemas para dormir, pesadillas, se despierta temprano, sonámbulo y frecuentemente despierta durante la noche

❏ No come delante de la gente, come después a esconidas

❏ Tiene dolores de estómago frecuentemente

O T R O S

¿Es su hijo propenso a tener accidentes? ¿Hay algo que le está causando tensión a su familia ahora? ¿Ha sido su hijo o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional? Si sí, ¿en qué forma?_________________ ¿Cuándo? ___________ ¿Empezó el tratamiento? ¿Corre el riesgo su hijo de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ¿Toma su hijo bebidas alcohólicas o drogas (incluyendo las de la calle y las que se venden sin receta)? ¿Ha recibido su hijo tratamiento por problemas de la salud mental o por el abuso de sustancias como drogas o bebidas alcohólicas?

❏ Sí ❏ Sí ❏ Sí

❏ No ❏ No ❏ No

❏ Sí ❏ Sí ❏ Sí ❏ Sí

❏ ❏ ❏ ❏

No No No No

Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)

Fecha:_____________ Firma:________________________________________________________________ Parentesco con el paciente:_____________________________________________ table

CH-333 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2

Risk Assessment for Lead Exposure: Parent Questionnaire, Form Pb-110 (2 Pages)

Risk Assessment for Lead Exposure: Parent Questionnaire

Form

CH.58

Pb - 110

The risk assessment questionnaire contains 6 questions that appear on page 2, and is designed to be administered to the parent by the healthcare provider. Questions are in English and Spanish to assist with Spanish speaking parents.

Instructions: ‡ 7KLVTXHVWLRQQDLUHPD\EHXVHGZLWKDQ\FKLOGZKHWKHURUQRWHQUROOHGLQ7H[DV+HDOWK6WHSV ‡ 0HGLFDLGUHTXLUHVDEORRGOHDGWHVWIRUDOO7H[DV+HDOWK6WHSVSDWLHQWVDWPRQWKVDQGPRQWKV )RUFKLOGUHQOHVVWKDQ\HDUVRI DJHFRPSOHWHDEORRGOHDGWHVWDWDQ\ILUVWFKHFNXSDIWHUDJHDQG PRQWKVLI WKHUHLVQRHYLGHQFHRI DSUHYLRXVEORRGOHDGWHVW ‡ $WDQ\YLVLW\RXPD\FKRRVHWRSHUIRUPDEORRGOHDGWHVWUDWKHUWKDQXVHWKHULVNDVVHVVPHQW TXHVWLRQQDLUH ‡ 5HIHUWRWKHWDEOHEHORZIRUVFKHGXOLQJXVHRI WKHULVNDVVHVVPHQWTXHVWLRQQDLUH ‡ $´\HVµRU´GRQ·WNQRZµDQVZHUWRDQ\TXHVWLRQRQWKHULVNDVVHVVPHQWTXHVWLRQQDLUHLQGLFDWHVWKDWD EORRGOHDGWHVWVKRXOGEHDGPLQLVWHUHG

Schedule for Blood Lead Testing and Use of Risk Assessment Questionnaire Child’s Age

Parent Questionnaire

6 months

YES

9 months

YES

12 months

Blood Lead Test

YES

15 months

YES

18 months

YES

24 months

YES

30 months

YES

3, 4, 5, and 6 years

YES

For more information, contact the Texas Childhood Lead Poisoning Prevention Program at: 1-800-588-1248 http://www.dshs.state.tx.us/lead Fax completed form to 512-458-7699, or mail to the address below. 7H[DV&KLOGKRRG/HDG3RLVRQLQJ3UHYHQWLRQ3URJUDP 32%2;‡$XVWLQ7;‡‡ZZZGVKVVWDWHW[XVOHDG3DJHRI 5HYLVHG

CH-334 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

Form

CHILDREN’S SERVICES HANDBOOK

Pb - 110

Risk Assessment for Lead Exposure: Parent Questionnaire

Healthcare Provider: For children less than 6 years of age, complete a blood lead test at any first checkup after age 12 and 24 months if there is no evidence of a previous blood lead test. 3DWLHQW·V1DPH 3URYLGHU·V1DPH

'2% $GPLQLVWHUHGE\

0HGLFDLG 'DWH

Parent Questionnaire 1 'RHV\RXUFKLOGOLYHLQRUYLVLWDKRPHGD\FDUHRURWKHUEXLOGLQJEXLOWEHIRUH" 2 'RHV\RXUFKLOGOLYHLQRUYLVLWDKRPHGD\FDUHRURWKHUEXLOGLQJZLWKRQJRLQJUHSDLUVRUUHPRGHOLQJ" 3 'RHV\RXUFKLOGHDWRUFKHZRQQRQIRRGWKLQJVOLNHSDLQWFKLSVRUGLUW" 4 'RHV\RXUFKLOGKDYHDIDPLO\PHPEHURUIULHQGZKRKDVRUGLGKDYHDQHOHYDWHGEORRGOHDGOHYHO" 5 ,V\RXUFKLOGDQHZO\DUULYHGUHIXJHHRUIRUHLJQDGRSWHH" 6 ,V\RXUFKLOGH[SRVHGWRDQ\RI WKHIROORZLQJLI