NAME: MEDICAID ID: DOB: Informant/Relationship: AGE: GENDER: MALE FEMALE Medical Home:

If child over 5 years: uncomplicated pregnancy, labor, delivery and nursery course: Y * N *If yes, proceed with “Family Medical History and Personal Medical History”

if < 5 years old Family Medical History

Pregnancy Abbreviations for relatives listed below. M-Mother MGM-Maternal Grandmother pGM-Paternal Grandmother G P AB F-Father MGF-Maternal Grandfather pGF-Paternal Grandfather S-Sibling MA-Maternal Aunt PA-Paternal Aunt Total number of living children: Weight gain/loss: MU-Maternal Uncle pU-Paternal Uncle Mother’s age at birth: Number of years between previous pregnancy and this child: ___ Anemia/blood disorder ___ hIV + individual in Trimester Prenatal Care Began: 1 2 3 ___ Heart disease before household (do not identify) Prenatal Care Provider: age 50 ___ other immunosuppression Vitamins: Y N Iron: Y N ___ Cholesterol ___ Dental decay req. treatment ___ Alcohol/drug abuse Maternal Complications ___ Hypertension/stroke __ tobacco use istory ___ Asthma/allergy ___ learning disorder H Vaginal bleeding Flu-like illness or high temp. ___ Cancer ___ Intellectual Disability Anemia Kidney or bladder infection ___ Diabetes ___ psychiatric disorder Hypertension STIs ___ Epilepsy/seizures ___ physical/sexual/emotional Rh negative Hepatitis (A, B, or C) ___ Kidney problems abuse Diabetes Exposure to TB or had TB ___ Muscle/bone disease ___ Domestic violence Premature labor Exposure to lead/chemicals ___ Genetic disease or ___ Childhood hearing Dental disease Injury/hospitalization/surgery major birth defects impairment ___ Tuberculosis ealth ealth Maternal Substance Use ___ Other/Explanation:

OTC meds:

Prescription meds: h

Tobacco: Personal Medical History Alcohol:

Street drugs: Immunizations current: Y N Record unavailable Caffeine: Dental care current: Y N Sealants: Y N Birth/Delivery Trauma/injuries Vision problems Hospitalizations Hearing problems Place of birth: Surgery Seizures Birth attendant: Medications Environmental toxin exposure Hours of labor: Anemia (lead, etc.) Term Premature (weeks): Early childhood caries Allergies More than two weeks overdue STIs Cancer Hepatitis Asthma Type of delivery: Strep throat Eczema Vaginal C-Section Forceps Other/Explanation: Ear infections Substance use Bladder/kidney infections (alcohol, drug, tobacco) Complications: Pneumonia Developmental delays/ Breech Multiple birth Other: Physical/sexual/ learning disorder emotional abuse Immune suppression Nursery Course Muscle/bone disease Psychiatric disorder Other/Explanation: Birth Weight: Birth Length: FOC: Difficulty with initial breathing Transfusion Jaundice req. treatment Heart murmur Infection Seizures NICU: days. Age at discharge: newborn blood screening (date/location): 1: 2: Date: newborn hearing test (in hospital): Pass Fail type of test: ABr oAE Unknown referral made: Y n Signature/title Critical congenital heart disease(in hospital): Pass Fail Comments: years Birth through 20 Signature/title If used for documentation: Medicaid ID: nAME: Date:

PROGRESS NOTES istory H ealth ealth h

Birth through 20 years Birth through 20

ECHR-1 06/2021