Healthchek Screening Forms

Ohio Department of Medicaid HEALTHCHEK SCREENING PACKET ODM 03518 (7/2014)

This packet contains one copy of the following material:

WELL CHILD EXAM - INFANCY: NEWBORN - 1 WEEK VISIT (pages 2 -4)

WELL CHILD EXAM - INFANCY: 4 WEEKS (pages 5 - 7)

WELL CHILD EXAM - INFANCY: 2 MONTHS (pages 8 - 10)

WELL CHILD EXAM - INFANCY: 4 MONTHS (pages 11 - 13)

WELL CHILD EXAM - INFANCY: 6 MONTHS (pages 14 - 16)

WELL CHILD EXAM - INFANCY: 9 MONTHS (pages 17 - 19)

WELL CHILD EXAM - EARLY CHILDHOOD: 12 MONTHS (pages 20 - 22)

WELL CHILD EXAM - EARLY CHILDHOOD: 15 MONTHS (pages 23 - 25)

WELL CHILD EXAM - EARLY CHILDHOOD: 18 MONTHS (pages 26 - 28)

WELL CHILD EXAM - EARLY CHILDHOOD: 24 MONTHS (pages 29 - 31)

WELL CHILD EXAM - EARLY CHILDHOOD: 30 MONTHS (pages 32 - 34)

WELL CHILD EXAM - EARLY CHILDHOOD: 3 YEAR (pages 35 - 37)

WELL CHILD EXAM - EARLY CHILDHOOD: 4 YEAR (pages 38 - 40)

WELL CHILD EXAM - EARLY CHILDHOOD: 5 YEAR (pages 41 - 43)

WELL CHILD EXAM - MIDDLE CHILDHOOD: 6 - 10 YEAR (pages 44 - 46)

WELL CHILD EXAM - EARLY ADOLESCENCE: 11 - 14 YEAR (pages 47 - 49)

WELL CHILD EXAM - ADOLESCENCE: 15 - 20 YEAR (pages 50 - 52)

This screening form was adapted by the Ohio Medicaid managed care plans and Ohio Department of Job and Family Services for the Healthchek-EPSDT Collaborative Performance Improvement Project. 040110 ODM 03518 (7/2014) JFS 03518 (1/2011) Page 1 of 55 Ohio Department of Medicaid WELL CHILD EXAM - INFANCY: NEWBORN - 1 WEEK VISIT Date

Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaints

Weight Percentile Length Percentile HC Percentile Temp. Pulse Resp. BP (if risk)

% % % Birth History Vaginal C-Section Anticipatory Guidance/Health Education Birth Wt. Gestation Complications Y N (X if discussed) Patient Unclothed Y N Interval History: Safety (Include injury/illness, visits to other health care Review of Physical Appropriate car seat placed in back seat providers, changes in family or home) Systems Exam Systems Keep home and car smoke-free

N A N A Keep hot liquids away from baby

General To protect baby, avoid crowded places

Appearance Don’t leave baby alone in tub or high Skin/nodes Apnea Y N Monitor places; always keep hand on baby Nutrition Jaundice Water temp. <120 degrees/test with wrist Breast every hours Head Never shake baby Formula oz every hours Nutrition With iron Y N Eyes Hold baby when feeding/don’t prop bottle Type or brand Breast on demand or feed iron-fortified formula Ears Breast milk or formula is only fluid/food infant City water Well water needs Elimination Nose Amount of diaper changes to expect Normal Abnormal Oropharynx Sleep Infant Care Normal (2-4 hours) Abnormal Thermometer use; antipyretics Gums/palate Additional area for comments on page 2 Wash hands often WIC Neck Avoid direct sun/use children’s sunscreen Y N Emergency procedures Maternal Infant Health Managed Care Program Lungs Infant Development (MCP) Y N Develop feeding/sleep routines Name Heart/pulses Put baby to sleep on back/Safe Sleep Screening and Procedures: Abdomen Put baby to sleep in own crib Neonatal Metabolic Screen in Chart Console, hold, cuddle, rock, play w/baby Y N Test Date Genitalia Normal Pending Today Family Adjustment Hearing Take time for self and partner Spine Responds to Sounds Substance Abuse, Child Abuse, Domestic Neonatal ABR or OAE results in chart Violence Prevention Extremities/hips Developmental Surveillance Rest/sleep when baby sleeps Social-Emotional Communicative Neurological Parental Well Being Cognitive Physical Development Postpartum Check-up, Family Planning Abnormal Findings and Comments Psychosocial/Behavioral Assessment Baby blues, postpartum depression

Y N Accept help from partner, family & friends Screening for Abuse Y N (see additional note area on next page) If At Risk Results of visit discussed with parent Y N Other Anticipatory Guidance Discussed: Vision -Parental observation/concerns Immunizations: Plan HepB Given in Hospital? History/Problem List/Meds Updated Y N Today Referrals Maternal Infant Health MCP WIC Help Me Grow Transportation Immunizations Reviewed TM Next Well Check: 1 month of age Immunizations Given & Charted - if not Children Special Health Care Needs Other referral Developmental Questions and Observations given, document rationale on Page 2 Other IMPACTSIIS checked/updated Provider Signature Labs Done Today Y N

WELL CHILD EXAM - INFANCY: NEWBORN - 1 WEEK VISIT

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the infant: Yes No Please tell me any concerns about the way your baby is behaving or developing:

My baby looks at me and listens to my voice. My baby calms down when picked up. My baby is sleeping well. My baby is eating well, sucking well. My baby can hear sounds. My baby looks at my face.

Ask the parent to respond to the following statements: Yes No I am sad more often than I am happy. I have more good days with my baby than bad days. I have people who help me when I get frustrated with my baby.

Provider to follow up as necessary

Developmental Milestones

Always ask parents if they have concerns about development or behavior. (You may use the following screening list, or a standardized developmental instrument or screening tool. Tool Used; ). Infant Development Parent Development Infant responds to soothing Yes No Looks at infant Yes No

Infant listens to voices Yes No Picks up and soothes infant Yes No

Infant fixates on human face, Yes No Listens to infant Yes No follows with eyes

Lifts head momentarily Yes No Talks to infant Yes No

Moves arms, legs, and head Yes No Touches infant Yes No

Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

This screening form was adapted by the Ohio Medicaid managed care plans and Ohio Department of Job and Family Services for the Healthchek-EPSDT Collaborative Performance Improvement Project. 040110 ODM 03518 (7/2014) JFS 03518 (1/2011) Page 3 of 55 Your Baby’s Health at 1 Week Health Tips Milestones Learn to know when your baby is hungry, so you can feed her Ways your baby is developing between 1 week and 1 months of before she cries. Your baby may get fussy or turn her head toward age. your body when you hold her. • Looks at your face when you hold him, follows you as you move. Breast milk is the perfect food for babies for at least the first year. • Pays attention to your voice. Try to breast-feed as long as possible. • Shows she hears sounds by startling, blinking, or crying. • Moves arms and legs, tries to lift head when lying on tummy. If you are giving your baby a bottle, hold him in your arms during • Tells you what he needs by fussing or crying. feedings. Your baby needs this special time with you.

• Starts to smile Immunizations (Shots) protect your baby from many very serious

diseases. Make sure your baby gets all of her shots on time. For Help or More Information

Breast feeding, food and health information: To lower the chance of your baby dying from Sudden Infant Death • Women, Infant, and Children (WIC) Program, call 1-800-755- Syndrome (SIDS), ALWAYS put your baby to sleep on his back in 4769, or visit the website at: a crib or bassinet. There should be no soft bedding, blankets, www.odh.ohio.gov/odhPrograms/ns/wicn/wic1.aspx pillows, bumper pads, sheepskins, or stuffed toys in the crib or • The National Women's Health Information Center Breastfeeding bassinet. Helpline. Call 1-800-994-9662, or visit the website at: www.4woman.gov/breastfeeding If you or your baby’s caregivers smoke, then STOP smoking. Ask • LA LECHE League – 1-800-LALECHE (525-3243), or visit the visitors who smoke to go outside away from your baby. No one website at: www.lalecheleague.org should smoke in the car or other areas when your baby or other children are present. Social Support Services: Contact the local county Department of Job and Family Services Keep your baby away from crowds and people who have colds and Healthchek Coordinator coughs. Make sure that people who hold or care for your baby wash their hands often. For families of children with special health care needs: Bureau for Children with Medical Handicaps, ODH Call your baby’s doctor or nurse before your next visit if you have 1-800-755-4769 (Parents) Visit the Website at: any questions or worries about your baby. http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx Parenting Tips Car seat safety: Help your baby learn by playing and talking with him.

• Contact the Auto Safety Hotline at 1-888-327-4236. Visit the Give your baby the gift of your attention. Take lots of time to hold website: http://www.safercar.gov/ her, look into her eyes, and talk softly. • To locate a Child Safety Seat Inspection Station, call 1-866- SEATCHECK (866-732-8243) or online at www.seatcheck.org Comfort your baby when he cries. Your baby fusses and cries to try to tell you what he wants. Holding will not spoil him. Depression after delivery: For information on depression after childbirth visit this website: Your baby needs “tummy time” to strengthen muscles. Place your http://postpartum.net/ or call the Postpartum Support International baby on her tummy when she is awake Postpartum Depression helpline at 1.800.944.4PPD When you are a parent, you will be happy, mad, sad, frustrated, If you’re concerned about your child’s development: angry, and afraid, at times. This is normal. If you feel very mad or Contact Help Me Grow at 1-800-755-GROW (4769) or at frustrated: www.ohiohelpmegrow.org/ . 1. Make sure your child is in a safe place (like a crib) and walk away. Domestic Violence hotline: 2. Call a good friend to talk about what you are feeling. National Domestic Violence Hotline - (800) 799-SAFE (7233) or 3. Call Cooperative Extension for classes-614.688.5378 online at http://www.ndvh.org/ 4. Call 800.448.3000 or visit Boystown Parenting Hotline at (http://www.parenting.org/hotline/index.asp ) Safety Tips

Use a rear-facing car seat for your baby on every ride. Buckle your baby up in the back seat, away from the air bag. They will not ask your name, and can offer helpful support and guidance. The helpline is open 24 hours a day. NEVER shake your baby. Shaking can cause very serious brain damage. Make sure everyone who cares for your baby knows this.

Ohio Department of Medicaid Date

WELL CHILD EXAM - INFANCY: 4 WEEKS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaints

Weight Percentile Length Percentile HC Percentile Temp. Pulse Resp. BP (if risk) % % % Birth History Vaginal C-Section Anticipatory Guidance/Health Education Birth Wt. Gestation Complications Y N (X if discussed) Safety Interval History: Patient Unclothed Y N (Include injury/illness, visits to other health care Appropriate car seat placed in back seat providers, changes in family or home) Review of Physical Keep home and car smoke-free Systems Exam Systems Keep hot liquids away from baby N A N A Smoke detectors General Don’t leave baby alone in tub or high places; Appearance always keep hand on baby Apnea Y N Monitor Skin/nodes Water temp. <120 degrees/test with wrist Nutrition Never shake baby Breast every hours Head Formula oz every hours Nutrition With iron Y N Eyes Hold baby when feeding/don’t prop bottle Type or brand Breast on demand or feed iron-fortified City water Well water Ears formula Elimination Delay solid foods until 4-6 months Normal Abnormal Nose

Sleep Infant Care Normal (2-4 hours) Abnormal Oropharynx Thermometer use; antipyretics Additional area for comments on page 2 Wash hands often WIC Gums/palate Avoid direct sun/use children’s sunscreen Y N Neck Emergency procedures Maternal Infant Health Managed Care Program

(MCP) Y N Lungs Infant Development Name Consistent feeding/sleep routines

Heart/pulses Screening and Procedures: Put baby to sleep on back/Safe Sleep Neonatal Metabolic Screen in Chart Tummy time while awake Y N Test Date Abdomen Console, hold, cuddle, rock, play w/baby Normal Pending Today Hearing Genitalia Family Adjustment Responds to Sounds Take time for self and partner Spine Neonatal ABR or OAE results in chart Substance Abuse, Child Abuse, Domestic Developmental Surveillance Violence Prevention Extremities/hips Social-Emotional Communicative Discuss child care, returning to work Cognitive Physical Development Neurological Psychosocial/Behavioral Assessment Parental Well Being Y N Abnormal Findings and Comments Postpartum Check-up, Family Planning Screening for Abuse Y N Baby blues, postpartum depression If At Risk Accept help from partner, family & friends (see additional note area on next page) IPPD (result) Other Anticipatory Guidance Discussed: Vision - Parental observation/concerns Results of visit discussed with parent Y N

Plan Immunizations: History/Problem List/Meds Updated HepB Given in Hospital? Referrals Next Well Check: 2 months of age Y N Today WIC Help Me Grow TM Transportation Immunizations Reviewed, Given & Charted Developmental Questions and Observations Maternal Infant Health MCP IMPACTSIIS checked/updated on Page 2 Children Special Health Care Needs Provider Signature Labs Done Today Y N Other referral Other

WELL CHILD EXAM - INFANCY: 4 WEEKS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the infant: Yes No Please tell me any concerns about the way your baby is behaving or developing:

My baby looks at me and listens to my voice. My baby calms down when picked up. My baby is sleeping well. My baby is eating well, sucking well. My baby can hear sounds. My baby looks at my face.

Provider to follow up as necessary

Infant responds to soothing Yes No Picks up and soothes infant Yes No

Infant listens to voices Yes No Listens to infant Yes No

Infant fixates on human face, Yes No Talks to infant Yes No follows with eyes

Lifts head momentarily Yes No Touches infant Yes No

Moves arms, legs, and head Yes No

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

This screening form was adapted by the Ohio Medicaid managed care plans and Ohio Department of Job and Family Services for the Healthchek-EPSDT Collaborative Performance Improvement Project. 040110 ODM 03518 (7/2014) JFS 03518 (1/2011) Page 6 of 55 Your Baby’s Health at 4 Weeks Health Tips Milestones Learn to know when your baby is hungry, so you can feed her Ways your baby is developing between 4 weeks and 2 months of before she cries. Your baby may get fussy or turn her head toward age. your body when you hold her. • Looks at your face when you hold him, follows you as you move Breast milk is the perfect food for babies for at least the first year. • Pays attention to your voice Try to breast-feed as long as possible. • Shows she hears sounds by startling, blinking, or crying • Moves arms and legs, tries to lift head when lying on tummy If you are giving your baby a bottle, hold him in your arms during • Tells you what he needs by fussing or crying feedings. Your baby needs this special time with you.

For Help or More Information Immunizations (Shots) protect your baby from many very serious Breast feeding, food and health information: diseases. Make sure your baby gets all of her shots on time.

• Women, Infant, and Children (WIC) Program, call 1-800-755- To lower the chance of your baby dying from Sudden Infant Death 4769, or visit the website at: Syndrome (SIDS), ALWAYS put your baby to sleep on his back in www.odh.ohio.gov/odhPrograms/ns/wicn/wic1.aspx a crib or bassinet. There should be no soft bedding, blankets, • The National Women's Health Information Center Breastfeeding pillows, bumper pads, sheepskins, or stuffed toys in the crib or Helpline. Call 1-800-994-9662, or visit the website at: bassinet. www.4woman.gov/breastfeeding • LA LECHE League - 1-800-LALECHE (525-3243), or visit the If you or your baby’s caregivers smoke, then STOP smoking. Ask website at: www.lalecheleague.org visitors who smoke to go outside away from your baby. No one should smoke in the car or other areas when your baby or other For families of children with special health care needs: children are present. Bureau for Children with Medical Handicaps, ODH 1-800-755-4769 (Parents) Visit the Website at: Keep your baby away from people who have colds and coughs. http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx Make sure that people who hold or care for your baby wash their Social Support Services: hands often.

Contact the local county Department of Job and Family Services Call your baby’s doctor or nurse before your next visit if you have Healthchek Coordinator any questions or worries about your baby.

Car seat safety: Parenting Tips • Contact the Auto Safety Hotline at 1-888-327-4236. Visit the Help your baby learn by playing and talking with him. website: http://www.safercar.gov/ • To locate a Child Safety Seat Inspection Station, call 1-866- Give your baby the gift of your attention. Take lots of time to hold SEATCHECK (866-732-8243) or online at www.seatcheck.org her, look into her eyes, and talk softly.

Depression after delivery: Comfort your baby when he cries. Your baby fusses and cries to For information on depression after childbirth visit this website: try to tell you what he wants. Holding will not spoil him. http://postpartum.net/ or call the Postpartum Support International Postpartum Depression helpline at 1.800.944.4PPD Your baby needs “tummy time” to strengthen muscles. Place your baby on her tummy when she is awake. If you’re concerned about your child’s development: Contact Help Me Grow at 1-800-755-GROW (4769) or at When you are a parent, you will be happy, mad, sad, frustrated, www.ohiohelpmegrow.org/ . angry, and afraid, at times. This is normal. If you feel very mad or frustrated: Domestic Violence hotline: 1. Make sure your child is in a safe place (like a crib) and walk National Domestic Violence Hotline - (800) 799-SAFE (7233) or away. online at http://www.ndvh.org/ 2. Call a good friend to talk about what you are feeling. 3. Call Cooperative Extension for classes-614. 688.5378 Safety Tips 4. Call 800.448.3000 or visit Boystown Parenting Hotline at Use a rear-facing car seat for your baby on every ride. Buckle your (http://www.parenting.org/hotline/index.asp ) baby up in the back seat, away from the air bag. They will not ask your name, and can offer helpful support and NEVER shake your baby. Shaking can cause very serious brain guidance. The helpline is open 24 hours a day. damage. Make sure everyone who cares for your baby knows this.

Date Ohio Department of Medicaid WELL CHILD EXAM - INFANCY: 2 MONTHS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaints

Weight Percentile Length Percentile HC Percentile Temp. Pulse Resp. BP (if risk)

% % % Birth History Vaginal C-Section Anticipatory Guidance/Health Education Birth Wt: Gestation Complications Y N (X if discussed) Interval History: Safety Patient Unclothed Y N (Include injury/illness, visits to other health care Appropriate car seat placed in back seat Review of Physical providers, changes in family or home) Keep home and car smoke-free Systems Exam Systems N A N A Keep hot liquids away from baby Don’t leave baby alone in tub or high places; General Appearance always keep hand on baby Apnea Y N Monitor Water temp. <120 degrees/test with wrist Skin/nodes Never shake baby Nutrition

Breast every hours Head/fontanel Nutrition Formula oz every hours Hold baby when feeding Eyes With iron Y N Breast on demand or feed iron-fortified Type or brand Ears formula City water Well water Delay solid foods until 4-6 months Elimination Nose Normal Abnormal Infant Development Sleep Oropharynx Put baby to sleep on back/Safe Sleep Normal (2-4 hours) Abnormal Learn baby’s temperament/responses Additional area for comments on page 2 Gums/palate Console, hold, cuddle, rock, play with baby WIC Y N Talk, sing, play music, and read to baby Neck Maternal Infant Health Managed Care Program Tummy time while awake Consistent feeding/sleep routines (MCP) Y N Lungs Name Strategies to deal with fussy periods

Screening and Procedures: Heart/pulses Family Adjustment Neonatal Metabolic Screen in Chart Encourage partner and other children (as Y N Test Date Abdomen appropriate) to help care for infant Normal Pending Today Genitalia Keep in contact with friends, family Subjective Hearing -Parental observation/ Substance Abuse, Child Abuse, Domestic concerns Spine Violence Prevention Subjective Vision -Parental observation/ Discuss child care, returning to work, play concerns Extremities/hips group Developmental Surveillance Neurological Social-Emotional Communicative Parental Well Being Cognitive Physical Development Family Planning Abnormal Findings and Comments Take time for self and spend time alone with Psychosocial/Behavioral Assessment your partner Y N Screening for Abuse Y N Other Anticipatory Guidance Discussed: (see additional note area on next page) Immunizations: Results of visit discussed with parent Y N Follow AAP/AAFP/CDC guidelines

Immunizations Reviewed Plan Immunizations Given & Charted - if not given, History/Problem List/Meds Updated document rationale Referrals Next Well Check: 4 months of age

WIC Help Me Grow TM Transportation IMPACTSIIS checked/updated Developmental Questions and Observations Maternal Infant Health MCP on Page 2 Acetaminophen mg. q. 4 hours Children Special Health Care Needs Provider Signature Labs Done Today Y N Other referral Other

WELL CHILD EXAM - INFANCY: 2 MONTHS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the infant: Yes No Please tell me any concerns about the way your baby is behaving or developing:

My baby looks at me and listens to my voice. My baby quiets when picked up. My baby is sleeping well. My baby is eating well, sucking well. My baby makes cooing sounds. My baby lifts his/her head while on tummy.

Provider to follow up as necessary

Developmental Milestones Always ask parents if they have concerns about development or behavior. (You may use the following screening list, or a standardized developmental instrument or screening tool. Tool used ). Infant Development Parent Development Coos and vocalizes reciprocally* Yes No Looks at infant Yes No Picks up and soothes infant or comforts Smiles responsively Yes No Yes No baby effectively Are parent and baby interested in and Follows to midline Yes No Yes No responsive to each other? Does parent seem depressed, angry, tired, Is attentive to voices, sounds, visual stimuli Yes No Yes No overwhelmed, or uncomfortable? Some head control in upright position Yes No

Shows pleasure interacting w/parent Yes No

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 2 Months Safety Tips Milestones Use a rear-facing car seat for your baby on every ride. Buckle Ways your baby is developing between 2 and 4 months of age. your baby up in the back seat, away from the air bag. • Likes to look at and be with familiar people • Shows excitement by waving arms and legs and smiles when NEVER shake your baby. Shaking can cause very serious brain you speak to her damage. Make sure everyone who cares for your baby knows • Eyes follow people and things this. • Lifts head and shoulders up when lying on tummy • Babbles and coos; smiles/laughs/squeals Health Tips • Likes toys that make sounds and tries to hold small toys “Well Child” check-ups help keep your baby healthy. Try not to • Begins to roll from side to side miss these doctor visits. If you do, call for another appointment.

For Help or More Information: Breast feeding, food and health information: Keep your baby’s immunization (shot) card in a safe place and • Women, Infant, and Children (WIC) Program, call 1-800-755- bring it to every doctor or clinic visit. 4769, or visit the website at: www.odh.ohio.gov/odhPrograms/ns/wicn/wic1.aspx Breast milk or formula is all that babies this age need to grow. • The National Women's Health Information Center Breastfeeding Avoid giving juice to your baby at this age. Sometimes your baby Helpline. Call 1-800-994-9662, or visit the website at: will need to eat more often than other times. This means he is www.4woman.gov/breastfeeding growing faster. • LA LECHE League - 1-800-LALECHE (525-3243). Visit the website at: www.lalecheleague.org You can keep breastfeeding when you go back to work. For information on breastfeeding and working, talk to your doctor or Social Support Services: nurse or call WIC or the La Leche League. Contact the local county Department of Job and Family Services Healthchek Coordinator Keep your baby away from people who are smoking. No one

For families of children with special health care needs: should smoke in the car or other areas when your baby or other Bureau for Children with Medical Handicaps, ODH children are present. Tobacco smoke may cause your baby to be 1-800-755-4769 (Parents) Visit the Website at: sick with breathing problems, ear infections, and may increase http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx the chance of Sudden Infant Death Syndrome (SIDS).

Car seat safety: Continue putting your baby to sleep on her back to lower the • Contact the Auto Safety Hotline at 1-888-327-4236. Visit the chance of SIDS. Make sure grandparents and other baby sitters website: http://www.safercar.gov/ also put your baby to sleep on her back. • To locate a Child Safety Seat Inspection Station, call 1-866- SEATCHECK (866-732-8243) or online at www.seatcheck.org Call your baby’s doctor or nurse before your next visit if you have any questions or concerns about your baby’s health, growth, or Depression after delivery: development. For information on depression after childbirth visit this website:

http://postpartum.net/ or call the Postpartum Support International Parenting Tips Postpartum Depression helpline at 1.800.944.4PPD Help your baby learn and grow by playing lovingly with him. If you’re concerned about your child’s development: Talk, read, and sing to your baby and look into her eyes. This Contact Help Me Grow at 1-800-755-GROW (4769) or at helps your baby know you love her. It also helps her brain grow. www.ohiohelpmegrow.org/ . When you are a parent, you will be happy, mad, sad, frustrated, Domestic Violence hotline: angry, and afraid, at times. This is normal. If you feel very mad National Domestic Violence Hotline - (800) 799-SAFE (7233) or or frustrated: online at http://www.ndvh.org/ 1. Make sure your child is in a safe place (like a crib) and walk away. Safety Tips 2. Call a good friend to talk about what you are feeling. Preventing burns: 3. Call Cooperative Extension for classes-614. 688.5378 ° Check to make sure the bath water is lukewarm, not hot, 4. Call 800.448.3000 or visit Boystown Parenting Hotline at before you put your baby in the water. (http://www.parenting.org/hotline/index.asp ) ° Avoid drinking hot coffee, hot tea, or other hot drinks while holding your baby. They will not ask your name, and can offer helpful support and ° Keep your baby out of the sun. Dress your baby in a hat with guidance. The helpline is open 24 hours a day. a rim and clothes that cover the arms and legs.

Date Ohio Department of Medicaid WELL CHILD EXAM - INFANCY: 4 MONTHS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaints

Weight Percentile Length Percentile HC Percentile Temp. Pulse Resp. BP (if risk)

% % % Birth History Vaginal C-Section Anticipatory Guidance/Health Education Birth Wt: Gestation Complications Y N (X if discussed)

Interval History: Patient Unclothed Y N Safety (Include injury/illness, visits to other health Appropriate car seat placed in back seat care providers, changes in family or home) Review of Physical Systems Exam Systems Use safety belt and don’t drive under the N A N A influence of alcohol or drugs General Keep home and car smoke-free Appearance Don’t leave baby alone in tub or high places; Apnea Y N Monitor always keep hand on baby Skin/nodes Nutrition Water temp. <120 degrees/test with wrist Don’t use baby walkers Breast every hours Head/fontanel Formula oz every hours Check home for sources of lead With iron Y N Eyes Nutrition Type or brand Breastfeed or give iron-fortified formula City water Well water Ears Avoid foods that contribute to allergies Solids Y N Introduce solid foods at 4-6 months Nose Elimination Wait one week or more to add new food Normal Abnormal Oropharynx Oral Health Sleep Discuss teething Gums/palate Normal (5-6 hours at night) Abnormal Discuss good family oral health habits Don’t share spoon or put pacifier in your mouth to Additional area for comments on page 2 Neck clean. WIC Y N Maternal Infant Health Managed Care Program Lungs Infant Development (MCP) Y N Consoling a fussy baby Heart/pulses Name Put baby to sleep on back/Safe Sleep Learn baby’s temperament Abdomen Screening and Procedures: Talk, sing, play music, and read to baby Subjective Hearing -Parental observation/ Establish daily and bedtime routines Genitalia concerns Family Adjustment Subjective Vision -Parental observation/ Spine Encourage partner to help care for infant concerns Take time for self and spend time alone with your Extremities/hips Developmental Surveillance partner Keep in contact with friends, family Social-Emotional Communicative Neurological Cognitive Physical Development Family Planning Choose responsible babysitters Abnormal Findings and Comments Psychosocial/Behavioral Assessment Discuss child care, returning to work

Y N Substance Abuse, Child Abuse, Domestic

Violence Prevention, Depression (see additional note area on next page) Screening for Abuse Y N Baby cannot be spoiled by holding, cuddling or Results of visit discussed with parent Y N If At Risk rocking Labs Done Today Y N Plan Other Anticipatory Guidance Discussed: Hct or Hgb History/Problem List/Meds Updated Immunizations: Referrals Follow AAP/AAFP/CDC guidelines WIC Help Me Grow TM Transportation Immunizations Reviewed Maternal Infant Health MCP Next Well Check: 6 months of age Immunizations Given & Charted - if not Children Special Health Care Needs given, document rationale Developmental Questions and Observations on Other referral Page 2 IMPACTSIIS checked/updated Other Provider Signature Acetaminophen mg. q. 4 hours

WELL CHILD EXAM - INFANCY: 4 MONTHS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the infant: Yes No Please tell me any concerns about the way your baby is behaving or developing

My baby cries when upset and seeks comfort. My baby smiles and laughs. My baby is sleeping well. My baby is eating and growing well. My baby can see and hear. My baby likes to look at and be with me. My baby reaches for objects and can hold them. My baby rolls or tries to roll over from tummy to back. My baby lets me know what it wants and needs.

Provider to follow up as necessary

Holds head upright in prone position Yes No Looks at infant and shares baby’s smiles Yes No

Laughs responsively Yes No The parent comforts baby effectively Yes No

Parent and baby are interested in and Follows past midline Yes No Yes No respond to each other Parent seems depressed, angry, tired, No persistent fist clenching Yes No Yes No overwhelmed, or uncomfortable

Raises body on hands Yes No Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not Seeks eye contact with parent Yes No anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Baby’s Health at 4 Months Safety Tips Milestones Use a rear-facing car seat for your baby on every ride. Buckle her Ways your baby is developing between 4 and 6 months of age. up in the back seat, away from the air bag. • Babbles using single consonants such as “dada” or “baba” • Smiles, laughs, and squeals responsively Keep the Poison Control Center phone number by your phone: 1- • Rolls over from front to back 800-222-1222

• Shows interest in toys Health Tips • Tries to pass toys from one hand to the other Check-ups are a good time to ask the doctor or nurse questions • May get upset when separated from familiar person(s) • about your baby. Make a list of questions before you go. Sits with support • Enjoys a daily routine Keep your baby’s immunization (shot) card in a safe place and bring it to every doctor or clinic visit. Babies can get shots even For Help or More Information: when they have a slight cold. Breast feeding, food and health information: • Women, Infant, and Children (WIC) Program, call 1-800-755- Your baby is still getting all the nutrition he needs from breast milk 4769, or visit the website at: or formula. Try to keep breast-feeding until your baby is at least www.odh.ohio.gov/odhPrograms/ns/wicn/wic1.aspx • 12 months old. Talk to your doctor about when to start your baby The National Women's Health Information Center Breastfeeding on cereal or other solid foods. This usually happens when your Helpline. Call 1-800-994-9662, or visit the website at: baby is 5 or 6 months old. www.4woman.gov/breastfeeding • LA LECHE League – 1-800-LALECHE (525-3243). Visit the Check how your baby sees and hears. Watch to see if her eyes website at: www.lalecheleague.org follow moving objects. Watch to see if she turns toward a loud or sudden sound. For families of children with special health care needs: Bureau for Children with Medical Handicaps, ODH Keep putting your baby to sleep on his back. Keep soft bedding 1-800-755-4769 (Parents) Visit the Website at: and stuffed toys out of the crib. Make sure your baby sleeps by http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx himself in a crib or portable crib. Social Support Services: Contact the local county Department of Job and Family Services Call your baby’s doctor or nurse before your next visit if you have Healthchek Coordinator any questions or concerns about your baby’s health, growth, or

development. Car seat safety:

• Contact the Auto Safety Hotline at 1-888-327-4236. Visit the Parenting Tips website: http://www.safercar.gov/ Sing, talk, read to and play with your baby every day. Look at • To locate a Child Safety Seat Inspection Station, call 1-866- your baby and repeat the sounds she makes. SEATCHECK (866-732-8243) or online at www.seatcheck.org

If you’re concerned about your child’s development: Put your baby on his tummy to play on the floor. Put toys close to Contact Help Me Grow at 1-800-755-GROW (4769) or at him so he can reach for them. www.ohiohelpmegrow.org/ .

Try to make a daily routine for you and your baby. For information about childhood immunizations:

Call the National Immunization Program Hotlines at 1 (800) 232- When you are a parent, you will be happy, mad, sad, frustrated, 4636 or online at http://www.cdc.gov/vaccines . angry, and afraid, at times. This is normal. If you feel very mad or For help finding childcare: frustrated: Bureau of Child Care and Development -800.886.3537 1. Make sure your child is in a safe place (like a crib) and walk http://www.odjfs.state.oh.us/cdc/query.asp away. 2. Call a good friend to talk about what you are feeling. Domestic Violence hotline: 3. Call Cooperative Extension for classes-614. 688.5378 National Domestic Violence Hotline - (800) 799-SAFE (7233) or 4. Call 800.448.3000 or visit Boystown Parenting Hotline at online at http://www.ndvh.org/ (http://www.parenting.org/hotline/index.asp )

Safety Tips They will not ask your name, and can offer helpful support and Always keep one hand on your baby when he is on a bed, sofa, or guidance. The helpline is open 24 hours a day. changing table so he does not roll off.

Never leave your baby alone in your home, car or community.

Ohio Department of Medicaid WELL CHILD EXAM - INFANCY: 6 MONTHS Date

Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaints

Weight Percentile Length Percentile HC Percentile Temp. Pulse Resp. BP (if risk) % % % Birth History Vaginal C-Section Anticipatory Guidance/Health Education Birth Wt: Gestation Complications Y N (X if discussed) Interval History : Safety (Include injury/illness, visits to other health care Patient Unclothed Y N Appropriate car seat placed in back seat providers, changes in family or home) Review of Physical Keep home and car smoke-free

Systems Exam Systems Avoid burns (stove, etc.); lower water heater

N A N A temperature

General Don’t leave baby alone in tub/high places Apnea Y N Monitor Appearance Childproof home - (hot liquids, alcohol, poisons, Nutrition medicines, outlets, cords, small- sharp objects, Breast every hours Skin/nodes plastic bags, safety locks) Formula oz every hours Head/fontanel Keep in highchair/playpen when in kitchen With iron Y N Limit time in sun/use sunscreen on baby Type or brand Eyes Don’t use baby walkers City water Well water Nutrition Solids Y N Ears Breastfeed or give iron-fortified formula Elimination Cup for water/juice - limit juice Normal Abnormal Nose Avoid foods that contribute to allergies Sleep Introduce solid foods at 4-6 months Normal (6 - 8 hours at night) Abnormal Oropharynx Wait one week or more to add new food Additional area for comments on page 2 Gums/palate/ Oral Health WIC Y N teeth Don’t put baby to bed with bottle Maternal Infant Health Managed Care Program Discuss teething (MCP) Y N Neck Assess fluoride/clean baby’s teeth daily Name Lungs Infant Development

Use upright seat so baby can see family Screening and Procedures: Heart/pulses Talk, sing, play music, and read to baby Oral Health Risk Assessment Daily and Bedtime Routine (put baby to bed Subjective Hearing - Parental observation/ Abdomen awake) concerns Safe Exploration Opportunities Subjective Vision - Parental observation/ Genitalia Put baby to sleep on back/Safe Sleep concerns Family Support and Relationships Spine Developmental Surveillance Family Planning Social-Emotional Communicative Chose responsible babysitters Extremities/hips Cognitive Physical Development Substance Abuse, Child Abuse, Domestic Psychosocial/Behavioral Assessment Neurological Violence Prevention, Depression Y N Consider parenting classes/support Screening for Abuse Y N Abnormal Findings and Comments groups/Playgroups If At Risk IPPD (result) Other Anticipatory Guidance Discussed: Lead level mcg/dl (see additional note area on next page) Labs Done Today Y N Results of visit discussed with parent Y N

Plan Immunizations: History/Problem List/Meds Updated Follow AAP/AAFP/CDC guidelines Referrals Immunizations Reviewed Next Well Check: 9 months of age WIC Help Me Grow TM Transportation Immunizations Given & Charted - if not Maternal Infant Health MCP Developmental Questions and Observations on given, document rationale Children Special Health Care Needs Page 2 IMPACTSIIS checked/updated Other referral Provider Signature Acetaminophen mg. q. 4 hours Other

WELL CHILD EXAM - INFANCY: 6 MONTHS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the infant: Yes No Please tell me any concerns about the way your baby is behaving or developing:

My baby seeks comfort when upset. My baby smiles and laughs. My baby says things like “da da” or “ba ba”. My baby eats some solid foods. My baby sits with help/support. My baby can pick up objects. My baby likes to look at and be with me. My baby rolls over.

Ask the parent to respond to the following statements: Yes No I am sad more often than I am happy. I have people who help me when I get frustrated. I am enjoying my baby more days than not. I have a daily routine that seems to work. I keep in contact with family and friends. I feel safe with my partner.

Provider to follow up as necessary

Developmental Milestones

Always ask parents if they have concerns about development or behavior. (You may use the following screening list, or a standardized developmental instrument or screening tool. Tool Used: ). Infant Development Parent Development Turns to sounds/voices Yes No Parent shows confidence with baby Yes No

Can be comforted most of the time Yes No Parent comforts baby effectively Yes No Parent and baby are interested in and Smiles, squeals and laughs responsively Yes No Yes No respond to each other Parent seems depressed, angry, tired, Has no head lag when pulled to sit Yes No Yes No overwhelmed, or uncomfortable Parent notices and responds to baby’s Yes No wants and needs Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Baby’s Health at 6 Months Safety Tips Milestones Make your home safe before for your baby starts to crawl. You Ways your baby is developing between 6 and 9 months of age. will need to keep doing this for several years. • Plays games like “peek-a-boo” ° Put away small objects and things that break • Babbles, imitates vocalizations ° Tape electric cords to the wall; put covers on outlets • Responds to own name ° Put safety gates at the top and bottom of stairs • Feeds herself with fingers and starts to drink from cup ° Store poisons and pills in a locked cabinet • Enjoys a daily routine ° Poison Control Center: 1-800-222-1222 • Sits up well and may pull to stand • Crawls, creeps, moves forward by scooting on bottom Baby walkers cause more injury than any other baby product. • May be unsure of strangers Instead of a walker, use a seat without wheels or put your baby • May comfort self by sucking thumb or holding special toy on his tummy on the floor. • May get upset when separated from familiar person Health Tips For Help or More Information: Signs that your baby is ready to start solid food: Breast feeding, food and health information: ° She can sit up with little or no support • Women, Infant, and Children (WIC) Program, call 1-800-755- ° She shows you she wants to try your food 4769, or visit the website at: ° She can use her tongue to push food into her throat www.odh.ohio.gov/odhPrograms/ns/wicn/wic1.aspx • The National Women's Health Information Center Breastfeeding Your baby will let you know when he has had enough to eat. Helpline. Call 1-800-994-9662, or visit the website at: Stop feeding your baby when he spits food out, closes his www.4woman.gov/breastfeeding mouth, or turns his head away. • LA LECHE League - 1-800-LALECHE (525-3243). Visit the website at: www.lalecheleague.org Let your baby begin to learn to drink from a cup. Put water, breast milk, or formula in it. Don’t let your baby take a bottle to Social Support Services: bed. Contact the local county Department of Job and Family Services Healthchek Coordinator Continue to put your baby to sleep on her back. Keep soft bedding and stuffed toys out of the crib. Make sure your baby Car seat safety: sleeps by herself in a crib or portable crib. • Contact the Auto Safety Hotline at 1-888-327-4236. Visit the website: www.safercar.gov/ Parenting Tips • To locate a Child Safety Seat Inspection Station, call 1-866- Show your baby picture books and talk about the pictures. Sing SEATCHECK (866-732-8243) or online at www.seatcheck.org simple songs and say nursery rhymes over and over.

Toy and Baby Product Safety: Give your baby plenty of time to play on his tummy on the floor. Consumer Product Safety Commission, 1-800-638-2772 or Put toys just out of reach so he will try to crawl. Start playing www.cpsc.gov/ simple games together like “Peek-a-Boo”, “Pat-a-Cake” and “So Prevention of Unintentional childhood injuries: Big”. National Safe Kids Campaign 1-202-662-0600 or www.usa.safekids.org/ Make regular times for eating, sleeping and playing with your baby. If you’re concerned about your child’s development: Bureau for Children with Medical Handicaps, ODH When you are a parent, you will be happy, mad, sad, frustrated, 1-800-755-4769 (Parents).Visit the Website at: http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx angry, and afraid, at times. This is normal. If you feel very mad or frustrated: For information about childhood immunizations: 1. Make sure your child is in a safe place (like a crib) and walk Call the National Immunization Program Hotlines at 1 (800) 232- away. 4636 or online at http://www.cdc.gov/vaccines . 2. Call a good friend to talk about what you are feeling.

3. Call Cooperative Extension for classes-614. 688.5378 Domestic Violence hotline: National Domestic Violence Hotline - (800) 799-SAFE (7233) or 4. Call 800.448.3000 or visit Boystown Parenting Hotline at online at http://www.ndvh.org/ (http://www.parenting.org/hotline/index.asp )

For help finding childcare: They will not ask your name, and can offer helpful support and Bureau of Child Care and Development -800.886.3537 guidance. The helpline is open 24 hours a day. http://www.odjfs.state.oh.us/cdc/query.asp

Ohio Department of Medicaid Date

WELL CHILD EXAM - INFANCY: 9 MONTHS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaints

Weight Percentile Length Percentile Wt for HC Percentile Temp Pulse Resp. BP (if risk) Length Percentile % % % % Interval History : Anticipatory Guidance/Health Education (Include injury/illness, visits to other health care Patient Unclothed Y N (X if discussed) providers, changes in family or home) Review of Physical Safety Systems Exam Systems Appropriate car seat placed in back seat N A N A Pool/water safety

General Poison Control Center: 1-800-222-1222 Appearance Childproof home - (hot liquids, cigarettes, Nutrition alcohol, poisons, medicines, outlets, gun Skin/nodes Breast every hours safety, cords, small/sharp objects, plastic Formula oz every hours bags) Head/fontanel With iron Y N Never shake baby Type or brand Eyes Limit time in sun/use hat & sunscreen City water Well water Check home for lead poisoning hazards Solids Y N Ears Elimination Nutrition Normal Abnormal Nose Breastfeed or give iron-fortified formula Sleep Encourage self-feeding, cup use Normal (8-10 hours at night) Abnormal Oropharynx 3 meals and 2-3 snacks w/variety of foods Additional area for comments on page 2 Gums/ palate/ Avoid foods that contribute to allergies WIC teeth Increase soft, moist table foods gradually Y N Neck Maternal Infant Health Program Infant Development Y N Talk, sing, play games and read to baby Lungs Consistent Daily/Bedtime Routine Screening and Procedures: Heart/pulses Changing sleep patterns Oral Health Risk Assessment Safe Exploration Opportunities Subjective Hearing -Parental observation/ Abdomen Play Pat a Cake, Peek a Boo, So Big concerns Crib Safety/lower mattress Subjective Vision -Parental observation/ Genitalia Avoid TV, videos, computers concerns LABS Spine Family Support and Relationships Standardized Developmental Screening Make time for self, partner, friends Extremities/hips Completed Tool Used Set examples and use simple words to discipline - don’t yell at, hit or shake baby RESULTS: No Risk At Risk Neurological Use consistent positive discipline Psychosocial/Behavioral Assessment Discuss baby’s explorations w/siblings Y N Abnormal Findings and Comments Chose responsible caregivers Screening for Abuse Y N Substance Abuse, Child Abuse, Domestic If At Risk Violence Prevention, Depression Lead level mcg/dl (see additional note area on next page)

Results of visit discussed with parent Y N Other Anticipatory Guidance Discussed: Immunizations:

Immunizations Reviewed Plan

Immunizations Given & Charted - if not History/Problem List/Meds Updated given, document rationale Referrals

Refer to AAP Guidelines WIC Help Me Grow Transportation Maternal Infant Health Program (MIHP) Next Well Check: 12 months of age IMPACTSIIS checked/updated Children Special Health Care Needs A standardized developmental screening tool Other referral should be administered (Medicaid required Other and AAP recommended) at the 9 month visit. Provider Signature

WELL CHILD EXAM - INFANCY: 9 MONTHS

Date Patient Name DOB

Developmental Questions and Observations A standardized developmental screening tool should be administered (Medicaid required and AAP recommended) at the 9 month visit. Ask the parent to respond to the following statements about the infant: Yes No Please tell me any concerns about the way your baby is behaving or developing

My baby understands some words. My baby shows feelings by smiling, crying and pointing. My baby says things like “da da” or “ba ba”. My baby can feed self with fingers. My baby likes to be with me. My baby is interested and explores new things. My baby is able to be happy, mad and sad. My baby can move around on his/her own. My baby plays games like “peek-a-boo”, “so big” or “pat-a-cake”.

Provider to follow up as necessary

Developmental Milestones Always ask parents if they have concerns about development or behavior. A standardized developmental screening tool should be administered at the 9 month visit (Medicaid required-Tool Used: ). In addition, the following should be observed: Infant Development Parent Development Responds to own name. Yes No Shares baby’s smiles Yes No

Seeks parent/caregiver for reassurance Yes No Talks to the baby in positive terms Yes No

Uses inferior pincer grasp Yes No Touches the baby gently Yes No Responsive, gentle and protective of the Shows interest in things around them Yes No Yes No baby Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when Sits without support Yes No the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Baby’s Health at 9 Months Health Tips Milestones Wash your hands often; especially after diaper changes and Ways your baby is developing between 9 and 12 months of age. before you feed your baby. Wash your baby’s toys with soap and • Pulls self up and moves holding onto furniture water.

• May start walking Slowly add foods that feel different to your baby. Foods that are • Points at things she wants crushed, blended, mashed, small chopped pieces, and soft lumps • Drinks from a cup and feeds himself – foods like mashed vegetables or cooked pasta. • Plays games such as Pat-a-Cake and Peek-a-Boo Let your baby drink some water, breast milk, or formula from a • Says 1-3 words (besides “mama,” “dada”) cup. • Enjoys books • Seeks parent for reassurance Keep soft bedding and stuffed toys out of the crib. Make sure • Picks thing up with thumb and one finger your baby sleeps by herself in crib or portable crib.

• Is able to be happy, mad and sad Call your baby’s doctor or nurse before your next visit if you have

any questions or concerns about your baby’s health, growth, or For Help or More Information: development. Breast feeding, food and health information: • Women, Infant, and Children (WIC) Program, call 1-800-755- Keep your baby’s new teeth healthy. Clean them after feedings. 4769, or visit the website at: Use the corner of a clean cloth or a tiny, soft toothbrush. Don’t let www.odh.ohio.gov/odhPrograms/ns/wicn/wic1.aspx your baby take a bottle to bed. • The National Women's Health Information Center Parenting Tips Breastfeeding Helpline. Call 1-800-994-9662, or visit the Read to your baby. Show your baby picture books and talk about website at: www.4woman.gov/breastfeeding the pictures. Sing songs and say nursery rhymes. • LA LECHE League – 1-800-LALECHE (525-3243). Visit the website at: www.lalecheleague.org Make your home safe and encourage your baby to explore.

Social Support Services: Babies develop in their own way. Your baby should keep learning Contact the local county Department of Job and Family Services and changing. If you think he is not developing well, talk to your doctor or nurse. Healthchek Coordinator

When you are a parent, you will be happy, mad, sad, frustrated, Car seat safety: angry, and afraid, at times. This is normal. If you feel very mad or • Contact the Auto Safety Hotline at 1-888-327-4236. Visit the frustrated: website: www.safercar.gov/ 1. Make sure your child is in a safe place (like a crib) and walk • To locate a Child Safety Seat Inspection Station, call 1-866- away. SEATCHECK (866-732-8243) or online at www.seatcheck.org 2. Call a good friend to talk about what you are feeling. 3. Call Cooperative Extension for classes-614. 688.5378 For information about lead screening: 4. Call 800.448.3000 or visit Boystown Parenting Hotline at Medicaid Consumer Hotline-800.324.8680 (http://www.parenting.org/hotline/index.asp )

Prevention of Unintentional childhood injuries: They will not ask your name, and can offer helpful support and National Safe Kids Campaign 1-202-662-0600 or guidance. The helpline is open 24 hours a day. www.usa.safekids.org/ Safety Tips For information if you’re concerned about your child’s Always watch your baby in the bathtub. Drowning can happen development: quickly and silently in only a few inches of water. Take your baby Bureau for Children with Medical Handicaps, ODH with you if you have to leave the room. 1-800-755-4769 (Parents).Visit the Website at: http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx Buckle up your baby in a car seat facing the rear of the car for the first year. Keep your baby in the back seat. It’s the safest place For information about childhood immunizations: for children to ride. Call the National Immunization Program Hotlines at 1 (800) 232- 4636 or online at http://www.cdc.gov/vaccines .

Domestic Violence hotline: National Domestic Violence Hotline - (800) 799-SAFE (7233) or online at http://www.ndvh.org/

Poison Control Center: 1-800-222-1222

Date Ohio Department of Medicaid WELL CHILD EXAM - EARLY CHILDHOOD: 12 MONTHS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaints

Weight Percentile Length Percentile HC Percentile Temp. Pulse Resp. BP (if risk)

% % % Interval History: Anticipatory Guidance/Health Education (Include injury/illness, visits to other health care Patient Unclothed Y N (X if discussed) providers, changes in family or home) Review of Physical Systems Exam Systems Safety N A N A Keep Poison Control number handy

General Appropriate car seat placed in back seat Appearance Pool/tub/water safety Nutrition Use gates, safety locks, window guards Breast every hours Skin/nodes Childproof home - (dangling cords, heaters, Formula oz every hours stairs, poisons, medicines, outlets, guns, Head/fontanel With iron Y N smoke detectors) Type or brand Eyes Supervise near pets, mowers, driveways, City water Well water streets

WIC Y N Ears Nutrition Discuss Weaning, use whole milk Elimination Nose Self Feeding (avoid hard small food) Normal Abnormal 3 nutritious meals, 2-3 healthy snacks Oropharynx Sleep Don’t force child to eat Normal (8 - 12 hours) Abnormal Gums/palate / teeth Oral Health Additional area for comments on page 2 If using bottle offer only water Neck Screening and Procedures: Brush toddler’s teeth twice a day with a soft toothbrush and water Oral Health Risk Assessment Lungs Subjective Hearing - Parental observation/ Schedule first dental exam concerns Heart/pulses Infant Development Subjective Vision - Parental observation/ Interactive talking, singing, and reading Abdomen concerns Daily/Bedtime Routine Hct or Hgb Encourage Safe Exploration Genitalia Lead level mcg/dl (required for Discourage hitting, biting, aggressive behavior Medicaid Spine Avoid TV, videos, computers

Family Support and Relationships Labs Extremities/hips Set simple limits (e.g., use distraction) Developmental Surveillance Praise good behavior Neurological Social-Emotional Communicative Set examples and use simple words to Cognitive Physical Development discipline – don’t yell at, hit or shake baby Abnormal Findings and Comments Special relationships with parents/caregivers

Psychosocial/Behavioral Assessment Encourage trusting relationships

Y N Young siblings should not supervise toddler (see additional note area on next page) Substance Abuse, Child Abuse, Domestic Screening for Abuse Y N Results of visit discussed with parent Y N Violence Prevention, Depression If At Risk Hold and cuddle child IPPD (result) Plan History/Problem List/Meds Updated Next Well Check: 15 months of age Immunizations: Fluoride Varnish Applied Referrals Immunizations Reviewed, Given & Charted - Developmental Questions and Observations WIC Help Me Grow on Page 2 if not given, document rationale Children Special Health Care Needs (Refer to AAP Guidelines) Transportation Dentist Provider Signature Impactsis (OH registry) updated Other Other

WELL CHILD EXAM - EARLY CHILDHOOD: 12 MONTHS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the toddler: Yes No Please tell me any concerns about the way your toddler is behaving or developing

My toddler likes to be with me. My toddler is interested in people, places and things. My toddler shows different feelings. My toddler drinks from a cup. My toddler eats a variety of foods. My toddler can make sounds. My toddler pulls self to standing position.

Ask the parent to respond to the following statements: Yes No I am sad more often than I am happy. I have people who help me when I get frustrated with my toddler. I am enjoying my time with my toddler. I have time for myself, partner and friends. I feel safe with my partner.

Provider to follow up as necessary

Says “Dada or Mama” specifically Yes No Positively talks, listens, and responds to Yes No Responds to No Yes No toddler Precise pincer grasp Yes No Parent is loving toward toddler Yes No Indicates wants by pointing or gestures Yes No Is able to transition from one activity to Yes No another throughout the day Uses words to tell toddler what is coming Yes No Appears to have a secure, attached next Yes No relationship with parent Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Baby’s Health at 12 Months Health Tips Milestones Make sure your child gets her immunizations (shots) on time to Ways your child is developing between 12 and 15 months of age. protect her from many serious diseases. If your child has missed • Speaks more and more words: 3-10 words by 15 months any shots, make an appointment to catch up.

• Stacks two or three blocks Your child should be eating different kinds of healthy foods. Eating • Walks well, climbs steps with help small pieces of soft table food can give your child the nutrition he • Follows simple directions needs. • Is curious and likes to explore people, places, and things Let your child drink from a cup. • Protests and says, “NO!”

• Touches, hugs, and kisses Call your child’s doctor or nurse before your next visit if you have any questions or concerns about your child’s health, growth, or For Help or More Information: development. Health and Nutrition program: • Women, Infant, and Children (WIC) Program, call 1-800-755- Parenting Tips 4769, or visit the website at: Play, read, and talk with your child every day. Repeat songs and www.odh.ohio.gov/odhPrograms/ns/wicn/wic1.aspx nursery rhymes that she likes.

Name your child’s feelings out loud – happy, sad or mad. Use Social Support Services: Contact the local county Department of words to tell him what is coming next. Your child can understand Job and Family Services Healthchek Coordinator more words than he can say.

For families of children with special health care needs call: Calmly, set limits to keep your child safe by giving her something Bureau for Children with Medical Handicaps, ODH different to do. Praise your child when she does things that you 1-800-755-4769 (Parents).Visit the Website at: like. http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx When you are a parent, you will be happy, mad, sad, frustrated, For help finding childcare: angry, and afraid, at times. This is normal. If you feel very mad or For help finding childcare: frustrated: Bureau of Child Care and Development -800.886.3537 1. Make sure your child is in a safe place (like a crib) and walk http://www.odjfs.state.oh.us/cdc/query.asp away. 2. Call a good friend to talk about what you are feeling. Car seat safety: 3. Call Cooperative Extension for classes-614. 688.5378 • Contact the Auto Safety Hotline at 1-888-327-4236. Visit the 4. Call 800.448.3000 or visit Boystown Parenting Hotline at website: www.safercar.gov/ (http://www.parenting.org/hotline/index.asp ). They will not ask • To locate a Child Safety Seat Inspection Station, call 1-866- your name, and can offer helpful support and guidance. The SEATCHECK (866-732-8243) or online at www.seatcheck.org helpline is open 24 hours a day.

For information about lead screening: Safety Tips Medicaid Consumer Hotline-800.324.8680 Your child should ride in a rear-facing child safety seat in the back seat of the vehicle as long as possible. He should be at least 12 Prevention of Unintentional childhood injuries: months old AND weigh at least 20 pounds before he is placed in a National Safe Kids Campaign 1-202-662-0600 or forward-facing toddler car seat. www.usa.safekids.org/ As your child learns to walk and climb, make sure your house is If you’re concerned about your child’s development: safe to explore. Keep the floor clean, lock poisons away, put Contact Help Me Grow at 1-800-755-GROW (4769) or at things that break on a high shelf, and keep gates closed on stairs. www.ohiohelpmegrow.org/ . Your child can choke on small objects. Keep small, hard, round Poison Prevention: objects (coins, small blocks) out of reach. Avoid giving round Call the Poison Control Center at 1-800-222-1222 or online at pieces of food, such as hot dog slices, grapes, or nuts to eat. www.mitoxic.org/pcc or www.spectrum-health.org

For information about childhood immunizations: Call the National Immunization Program Hotlines at 1 (800) 232- 4636 or online at http://www.cdc.gov/vaccines

Domestic Violence hotline: National Domestic Violence Hotline - (800) 799-SAFE (7233) or online at http://www.ndvh.org/

Ohio Department of Medicaid Date

WELL CHILD EXAM - EARLY CHILDHOOD: 15 MONTHS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaint

Weight Percentile Length Percentile Wt. for HC Percentile Temp. Pulse Resp. BP length Percentile % % % % Anticipatory Guidance/Health Education Interval History: Patient Unclothed Y N (X if discussed)

Subjective Hearing -Parental observation/ teeth Don’t share utensils or cups concerns Sleep Routines and Issues Neck Subjective Vision -Parental observation/ Bedtime Routine Strategies for night waking concerns Lungs Don’t put to bed with bottle Child Development and Behavior Developmental Surveillance Heart/pulses Social-Emotional Communicative Stranger anxiety & separation anxiety Promote child’s language by using simple Cognitive Physical Development Abdomen clear words and phrases

Genitalia Allow child choices acceptable to you Psychosocial/Behavioral Assessment Speak to your child reassuringly Y N Spine Use distraction e.g. an alternative activity Screening for Abuse Y N Praise good behavior and activities Extremities/hips Use discipline to teach, not punish Immunizations: Family Support and Relationships Neurological Immunizations Reviewed, Given & Charted - Keep family outings short and simple Help child express emotions appropriately if not given, document rationale Abnormal Findings and Comments Substance Abuse, Child Abuse, Domestic Refer to AAP immunization guidelines Violence Prevention, Depression Impactsis (OH registry) updated (see additional note area on next page)

Results of visit discussed with parent Y N Other Anticipatory Guidance Discussed: Labs Plan

History/Problem List/Meds Updated

Fluoride Varnish Applied

Referrals Next Well Check: 18 months of age Acetaminophen mg. q. 4 hours WIC Help Me Grow Developmental Questions and Observations Children Special Health Care Needs on Page 2 Transportation □ Dentist Provider Signature Other Other

WELL CHILD EXAM - EARLY CHILDHOOD: 15 MONTHS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the toddler: Yes No Please tell me any concerns about the way your toddler is behaving or developing:

My toddler likes to be with me. My toddler is interested in people, places and things. My toddler shows different feelings. My toddler feeds self with fingers/spoon and drinks from a cup. My toddler can stack 2 - 3 blocks.

Developmental Milestones Always ask parents if they have concerns about development or behavior. A standardized developmental and autism screening tool should be administered at the 18 month visit (Medicaid required-Tool Used ). If the child is unlikely to return for an 18 month visit, the standardized screens should be completed at the 15 month visit. In addition, the following should be observed: Toddler Development Parent Development Understands simple commands Yes No Appropriately disciplines toddler Yes No Walks without support Yes No

Says at least 3 - 5 words Yes No Positively talks, listens, and responds to Yes No Indicates wants by pointing or gestures. Yes No toddler Is able to transition from one activity to Yes No Parent is loving toward toddler Yes No another throughout the day Appears to have a secure and attached Uses words to tell toddler what is coming Yes No Yes No relationship with parent next Please note: Any concerns raised during surveillance should be promptly addressed with standardized developmental screening tests. In addition, screening tests should be administered regularly at the 9-, 18-, and 24- or 30- month visits ( AAP, 2006, Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening)

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Baby’s Health at 15 Months Health Tips Milestones Your child’s check-ups will be spaced farther apart as your child Ways your child is developing between 15 and 18 months of age. gets older. If you have concerns between checkups, be sure to • Says phrases of at least two words call the doctor or nurse and ask questions.

• Walks, may run a bit, climbs up or down one stair Check to make sure your child has had all the shots he needs. If • Likes pull toys and likes being read to your child has missed some shots, make an appointment to get • Is curious and likes to explore people, places and things them soon. Your child needs all of the required shots to have the • Protests and says, “NO!” best protection against serious diseases.

• Imitates others Your child’s appetite may be less than in the past. Offer a variety • Kisses and shows affection of healthy foods. Let her decide how much of each food to eat. • Makes marks with a crayon Do not force her to finish food.

For Help or More Information: Your child needs two cups of milk or yogurt, or three slices of Car seat safety: cheese each day. Avoid low-fat foods until age 2. • Contact the Auto Safety Hotline at 1-888-327-4236 or online at www.nhtsa.dot.gov Each child develops in his own way, but you know your child best. • To locate a Child Safety Seat Inspection Station, call 1-866- If you think he is not developing well, you can get a free screening. SEATCHECK (866-732-8243) or online at www.seatcheck.org Call your child’s doctor or nurse if you have questions.

For information about childhood immunizations: Parenting Tips Call the National Immunization Program Hotlines at 1 (800) 232- Name your child’s feelings out loud – happy, sad or mad. Use 4636 or online at http://www.cdc.gov/vaccines . words to tell her what is coming next. Your child can understand more words than she can say. Give your child simple choices. Social Support Services: Example “squash or peas?” Contact the local county Department of Job and Family Services Calmly set limits for your child by giving him something different to Healthchek Coordinator do. Praise him when he does things that you like.

For information about lead screening: When you are a parent you will be happy, mad, sad, frustrated, Medicaid Consumer Hotline-800.324.8680 angry and afraid, at times. This is normal. If you feel very mad or frustrated: Posion Prevention: 1. Make sure your child is in a safe place (like a crib) and walk Call the Poison Control Center at 1-800-222-1222 away. 2. Call a good friend to talk about what you are feeling. If you’re concerned about your child’s development: 3. Call Cooperative Extension for classes-614. 688.5378 Contact Help Me Grow at 1-800-755-GROW (4769) or at 4. Call 800.448.3000 or visit Boystown Parenting Hotline at www.ohiohelpmegrow.org/ . (http://www.parenting.org/hotline/index.asp )

Parenting skills or support: Call Cooperative Extension for classes-614. 688.5378 They will not ask your name, and can offer helpful support and guidance. The helpline is open 24 hours a day. For families of children with special health care needs: Bureau for Children with Medical Handicaps, ODH Safety Tips 1-800-755-4769 (Parents).Visit the Website at: Falls often cause young children to get hurt. Take your child to a http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx safe playground. Find one that has padding, sand, or wood chips under the toys. Look for small toys that fit a toddler. Stay close to

your child while he is playing. Prevention of Unintentional childhood injuries:

National Safe Kids Campaign 1-202-662-0600 or www.safekids.org Your child may try to get out of her car seat. Avoid letting her get

Domestic Violence hotline: out, because then she will try again and again. ° If she tries, be firm, stop the car, and refuse to move until she National Domestic Violence Hotline - (800) 799-SAFE (7233) or stays buckled in. online at www.ndvh.org ° Take soft toys, picture books, and music to entertain your

child in the car. For help finding childcare: ° Wear your own seat belt, too. Bureau of Child Care and Development -800.886.3537 http://www.odjfs.state.oh.us/cdc/query.asp

WELL CHILD EXAM - EARLY CHILDHOOD: 18 MONTHS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaint

(Include injury/illness, visits to other health care Safety providers, changes in family or home) Review of Physical Keep Poison Control number handy Systems Exam Systems Appropriate car seat placed in back seat N A N A Parents use of seat belts General Appearance Use stair gates, safety locks, window guards Nutrition Childproof home - (window guards, cleaners, Skin/nodes Whole milk, cup only medicines, outlets, guns, dangling cords) Supervise near mowers, driveways, streets Solids servings per day Head/fontanel Smoke detectors, keep matches out of sight City water Well water Check home for lead poisoning hazards WIC Y N Eyes Elimination Normal Abnormal Nutrition Ears Sleep Offer child a new food several times Let toddler decide what/how much to eat Normal (8 - 12 hours) Abnormal Nose Additional area for comments on page 2 3 nutritious meals, 2-3 healthy snacks Oropharynx Oral Health Screening and Procedures: Gums/palate/ Don’t put toddler to bed with bottle Oral Health Risk Assessment teeth Brush toddler’s teeth w/soft toothbrush Subjective Hearing -Parental observation/ Neck Child Development and Behavior concerns Set specific limits, be consistent Subjective Vision -Parental observation/ Lungs Delay Toilet Training until child is ready concerns May be anxious with new people/situations Standardized Developmental Screening Heart/pulses Interactive talking, playing, singing, reading Completed Use simple clear phrases with your child Abdomen Tool Used Help child focus on another activity when upset RESULTS: No Risk At Risk Genitalia Autism Screening Praise good behavior and accomplishments Use discipline to teach, not punish Completed Spine RESULTS: No Risk At Risk Family Support and Relationships Extremities/hips Psychosocial/Behavioral Assessment Keep family outings short and simple Y N Allow older children their own space/ toys Neurological Screening for Abuse Y N Help child express emotions appropriately Eat meals as a family Abnormal Findings and Comments Substance Abuse, Child Abuse, Domestic If Risk: Violence Prevention, Depression IPPD (result) Other Anticipatory Guidance Discussed: Hct or Hgb (result) (see additional note area on next page) Lead level mcg/dl Results of visit discussed with parent Y N

Labs Plan History/Problem List/Meds Updated Next Well Check: 24 months of age Immunizations : Fluoride Varnish Applied Immunizations Reviewed, Given & Charted - Referrals A standardized developmental and autism if not given, document rationale WIC Help Me Grow Dentist screening tool should be administered (Medicaid required & AAP recommended) at (Refer to AAP immunization guidelines) Children Special Health Care Needs the 18 month visit. Impactsis (OH registry) updated Transportation Other For M-Chat autism screening tool, go to: Acetaminophen mg. q. 4 hours Other http://www.firstsigns.org/downloads/m- chat.PDF Provider Signature

WELL CHILD EXAM - EARLY CHILDHOOD: 18 MONTHS

Date Patient Name DOB

Developmental Questions and Observations A standardized developmental and autism screening tool should be administered (Medicaid required and AAP recommended) at the 18 month visit.

Ask the parent to respond to the following statements about the toddler: Yes No Please tell me any concerns about the way your toddler is behaving or developing:

Developmental Milestones A standardized developmental and autism screening tool should be administered (Medicaid required) at the 18 month visit. (Medicaid required-Tool Used: ). For M-CHATs Screening Tool go to http://www.firstsigns.org/downloads/m-chat.PDF . Always ask parents if they have concerns about development or behavior. In addition, the following should be observed: Toddler Development Parent Development Understands simple commands Yes No Appropriately disciplines toddler Yes No Walks well, stoops Yes No

Says 3 - 10 words Yes No Positively talks, listens, and responds to Yes No Indicates wants by pointing or gestures. Yes No toddler Is able to transition from one activity to Yes No Parent is loving toward toddler Yes No another throughout the day Appears to have a secure and attached Uses words to tell toddler what is coming Yes No Yes No relationship with parent next Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 18 Months Health Tips Milestones Your child’s check-ups will be spaced farther apart as your child Ways your child is developing between 18 and 24 months. gets older. If you have concerns between checkups, be sure to • Says phrases of at least two words call the doctor or nurse and ask questions.

• Stacks five or six blocks Check to make sure your child has had all the shots he needs. If • Is curious and likes to explore people, places and things your child has missed some shots, make an appointment to get • Protests and says, “NO!” them soon. Your child needs all of the required shots to have the • Kicks and throws a ball best protection against serious diseases.

• Imitates adults Your child’s appetite may be less than in the past. Offer her a • Kisses and shows affection variety of healthy foods. Let her decide how much of each food to • Follows two-step directions eat. Do not force her to finish food.

For Help or More Information: Your child needs two cups of milk or yogurt, or three slices of Car seat safety: cheese each day. Avoid low-fat foods until age 2. • Contact the Auto Safety Hotline at 1-888-327-4236 or online at www.nhtsa.dot.gov Each child develops in his own way, but you know your child best. If you think he is not developing well, you can get a free screening. • To locate a Child Safety Seat Inspection Station, call 1-866- Call your child’s doctor or nurse if you have questions. SEATCHECK (866-732-8243) or online at www.seatcheck.org

Parenting Tips For information about childhood immunizations: Name your child’s feelings out loud – happy, sad or mad. Use Call the National Immunization Program Hotlines at 1 (800) 232- words to tell her what is coming next. Your child can understand 4636 or online at http://www.cdc.gov/vaccines . more words than she can say. Give your child simple choices.

Example “squash or peas?” For information about lead screening:

Medicaid Consumer Hotline-800.324.8680 Calmly set limits for your child by giving him something different to

do. Praise him when he does things that you like. Poison Prevention:

Call the Poison Control Center at 1-800-222-1222 or online at When you are a parent you will be happy, mad, sad, frustrated, www.mitoxic.org/pcc or www.spectrum-health.org angry and afraid, at times. This is normal. If you feel very mad or frustrated: Social Support Services: Contact the local county Department of 1. Make sure your child is in a safe place (like a crib) and walk Job and Family Services Healthchek Coordinator away. 2. Call a good friend to talk about what you are feeling. For help finding childcare: 3. Call Cooperative Extension for classes-614. 688.5378 Bureau of Child Care and Development -800.886.3537 4. Call 800.448.3000 or visit Boystown Parenting Hotline at http://www.odjfs.state.oh.us/cdc/query.asp (http://www.parenting.org/hotline/index.asp ). They will not ask your name, and can offer helpful support and guidance. If you’re concerned about your child’s development: The helpline is open 24 hours a day. Contact Help Me Grow at 1-800-755-GROW (4769) or at www.ohiohelpmegrow.org/ . Safety Tips Falls often cause young children to get hurt. Take your child to a Parenting skills or support: safe playground. Find one that has padding, sand, or wood chips Call Cooperative Extension for classes-614. 688.5378 under the toys. Look for small toys that fit a toddler. Stay close to your child while they are playing. Support for families of children with special health care needs: Your child may try to get out of her car seat. Avoid letting her get Children Special Health Care Services, Family phone line at 1-800- out, because then she will try again and again. 359-3722 Bureau for Children with Medical Handicaps, ODH ° If she tries, be firm, stop the car, and refuse to move until she 1-800-755-4769 (Parents).Visit the Website at: stays buckled in. http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx ° Take soft toys, picture books, and music to entertain your child in the car. Prevention of Unintentional childhood injuries: ° Wear your own seat belt, too. National Safe Kids Campaign 1-202-662-0600 or www.safekids.org .

Domestic Violence hotline: National Domestic Violence Hotline - (800) 799-SAFE (7233) or online at www.ndvh.org

Ohio Department of Medicaid Date

WELL CHILD EXAM - EARLY CHILDHOOD: 24 MONTHS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaints

Weight Percentile Length Percentile HC Percentile BMI Temp. Pulse Resp. BP

% % % Anticipatory Guidance/Health Education Interval History: Patient Unclothed Y N (X if discussed) (Include injury/illness, visits to other health care Safety providers, changes in family or home) Review of Physical Teach child to wash hands, wipe nose Systems Exam Systems w/tissue N A N A Limit screen time, watch programs together General Appearance Appropriate car seat placed in back seat Nutrition Pool/tub/water safety Skin/nodes Grains servings per day Use bike helmet Childproof home - (hot liquids/pots, window Fruit/Vegetable servings per day Head/fontanel guards, cleaners, medicines, knives, guns) Whole Milk servings per day Supervise near pets, mowers, streets Meat/Beans servings per day Eyes Supervise play, ensure playground safety City water Well water Bottled water Ears Parents use of seat belts WIC Y N Nutrition/physical safety Nose Eat meals as a family Elimination Normal Abnormal 3 nutritious meals, 2-3 healthy snacks Oropharynx Let toddler decide what/how much to eat Sleep Family physical activity Normal (8 -12 hours) Abnormal Gums/palate/ Physical activity in a safe environment teeth Additional area for comments on page 2 Oral Health Neck Dental appointment Screening and Procedures: Brush teeth w/fluoridated toothpaste Lungs Child Development and Behavior Oral Health Risk Assessment Listen to and respect your child Lead level mcg/dl (required for Heart/pulses Reinforce limits, be consistent Medicaid) Begin toilet training when child is ready Subjective Hearing -Parental observation/ Abdomen Hug, talk, read, and play together concerns Model appropriate language Subjective Vision -Parental observation/ Genitalia Encourage self-expression, choices concerns Praise good behavior and accomplishments Spine Use positive discipline Autism Screening Completed Extremities/hips Family Support and Relationships RESULTS: No Risk At Risk Don’t expect toddler to share all toys Help child express emotions Developmental Surveillance Neurological Substance Abuse, Child Abuse, Domestic Social-Emotional Communicative Violence Prevention, Depression Abnormal Findings and Comments Cognitive Physical Development Discuss child care, play groups, preschool,

early intervention programs, parenting Psychosocial/Behavioral Assessment Other Anticipatory Guidance Discussed: Y N (see additional note area on next page) Results of visit discussed with parent Y N Screening for Abuse Y N If Risk: Plan IPPD (result) History/Problem List/Meds Updated Hct or Hgb (result) Fluoride Varnish Applied Next Well Check: 30 months of age Dyslipidemia (result) Referrals An autism screening tool should be Labs WIC Help Me Grow administered at the 24 month visit. Children Special Health Care Needs For M-Chat autism screening tool, go to: Immunizations: Transportation Dentist http://www.firstsigns.org/downloads/m- chat.PDF Immunizations Reviewed, Given & Charted - Other Developmental Questions and Other if not given, document rationale Observations on Page 2 (Refer to AAP Guidelines) Provider Signature Impactsis (OH registry) updated

WELL CHILD EXAM - EARLY CHILDHOOD: 24 MONTHS

Date Patient Name DOB

Developmental Questions and Observations An autism screening tool should be administered at the 24 month visit. If a standardized developmental screening was not completed at 18 months or the child is unlikely to return for a 30 month visit, the standardized screen should occur at the 24 month visit.

Ask the parent to respond to the following statements about the toddler: Yes No Please tell me any concerns about the way your toddler is behaving or developing

My toddler likes to be with me. My toddler is interested in people, places and things. My toddler smiles, laughs, protests and says, “No”. My toddler uses 2-3 word phrases. My toddler eats a variety of foods. My toddler can stack 5-6 blocks. My toddler can kick a ball.

Ask the parent to respond to the following statements: Yes No I have people who help me when I get frustrated with my toddler. I am enjoying my time with my toddler. I have time for myself, partner and friends. I feel safe with my partner.

Provider to follow up as necessary

Developmental Milestones Always ask parents if they have concerns about development or behavior. A standardized autism screening tool should be administered at the 24 month visit (Medicaid required-Tool Used: ). If a standardized developmental screening was not completed at 18 months or the child is unlikely to return for a 30 month visit, the standardized screen should occur at the 24 month visit. For M-Chat autism screening tool, go to: http://www.firstsigns.org/downloads/m-chat.PDF . In addition, the following should be observed: Toddler Development Parent Development Understands two step verbal commands Yes No Appropriately disciplines toddler Yes No Imitates adults Yes No

Vocabulary of at least 50 words Yes No Positively talks, listens, and responds to Yes No Uses words to communicate with others Yes No toddler Points to 6 named body parts (nose, eyes, Yes No Parent is loving toward toddler. Yes No ears, mouth, hands, feet, tummy, hair) Avoids eye contact and touch Yes No Uses words to tell toddler what is coming Yes No Often fearful and irritable Yes No next

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 24 Months Health Tips : Milestones Are your child’s shots up to date? Ask your child’s doctor or nurse Ways your child is developing between 2 and 2 ½ years of age. about a flu shot for your child.

• May not want to do what parent wants; says, “NO” often Offer your child a variety of healthy foods every day. Limit junk foods. Eat meals together as a family as often as possible. Turn • Likes to explore off the TV while eating together. • Shows feelings and is playful with others • Jumps in place, kicks a ball Brush your child’s teeth at least once a day with a pea-sized • Uses short 3 - 4 word phrases amount of fluoride toothpaste. Make sure your child gets a dental checkup once a year. • Can point to 6 body parts

• May have fears about unexpected changes Each child develops in her own way, but you know your child best. • Begins to play with other children If you think she is not developing well, you can get a free • Is able to feed and dress self screening. Call your child’s doctor or nurse if you have questions.

• Plays “make believe” games with dolls and stuffed animals Parenting Tips :

Take your child outside to play and help him enjoy active games For Help or More Information : like catch, tag, and hide-and-seek. Give your child simple toys to Safe Gun Storage Information: play with, like blocks, crayons and paper, and stuffed animals. Call 1-202-662-0600 or go to www.usa.safekids.org

You may want your child to be toilet trained soon, but she may not For help finding childcare: be ready until about age 3. Your child will show you when she is Bureau of Child Care and Development -800.886.3537 ready by being dry after sleep and telling you when she wants to http://www.odjfs.state.oh.us/cdc/query.asp use the toilet.

Social Support Services: Don’t spank or yell at your child. Calmly, give your child something Contact the local county Department of Job and Family Services different to do. Use words to tell child when he or she is doing Healthchek Coordinator something good. Help children understand how they are feeling by naming the feeling. For information about lead screening: Medicaid Consumer Hotline-800.324.8680 When you are a parent you will be happy, mad, sad, frustrated, angry and afraid, at times. This is normal. If you feel very mad or Poison Prevention: frustrated: Call the Poison Control Center at 1-800-222-1222 1. Make sure your child is in a safe place and walk away. 2. Call a good friend to talk about what you are feeling. If you’re concerned about your child’s development: 3. Call Cooperative Extension for classes-614. 688.5378 Contact Help Me Grow at 1-800-755-GROW (4769) or at 4. Call 800.448.3000 or visit Boystown Parenting Hotline at www.ohiohelpmegrow.org/ . (http://www.parenting.org/hotline/index.asp )

Parenting skills or support: They will not ask your name, and can offer helpful support and Call Cooperative Extension for classes-614. 688.5378 guidance. The helpline is open 24 hours a day.

Support for families of children with special health care Safety Tips needs: ° Keep cleaning supplies and medicine locked up and out of Bureau for Children with Medical Handicaps, ODH reach 1-800-755-4769 (Parents).Visit the Website at: ° Always hold your child’s hand while walking near traffic, http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx including in parking lots. Check behind your car before backing up, in case a child is behind it Domestic Violence hotline: ° If you have guns at home, keep them unloaded and locked up National Domestic Violence Hotline - (800) 799-SAFE (7233) or ° Put a life jacket on your child whenever they are near the online at www.ndvh.org water or in a boat. Always watch them around the water ° Keep matches and lighters out of reach National Safe Kids Campaign: 1-202-662-0600 or www.safekids.org .

For information about childhood immunizations: Call the National Immunization Program Hotlines at 1 (800) 232- 4636 or online at http://www.cdc.gov/vaccines .

Date Ohio Department of Medicaid WELL CHILD EXAM - EARLY CHILDHOOD: 30 MONTHS Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaint(s)

Weight Percentile Length Percentile BMI Percentile BP Temp. Pulse Resp.

% % % Anticipatory Guidance/Health Education Interval History: Patient Unclothed Y N (X if discussed)

(Include injury/illness, visits to other health care Safety providers, changes in family or home) Review of Physical Working smoke detectors/fire escape plan Systems Exam Systems Appropriate car seat placed in back seat N A N A Pool/tub/water safety General Appearance Use bike helmet Nutrition Animal and Pet Safety Skin/nodes Grains servings per day Childproof home - (hot liquids/pots, window guards, cleaners, medicines, knives, guns) Fruit/Vegetables servings per day Head/fontanel Supervise near pets, mowers, streets Whole Milk servings per day Supervise play, ensure playground safety Meat/Beans servings per day Eyes Limit time in sun-use hat/sunscreen City water Well water Bottled water Ears Nutrition/physical activity WIC Y N Eat meals as a family Nose Family physical activity Elimination Normal Abnormal Physical activity in a safe environment Oropharynx Oral Health Sleep Gums/palate Dental appointment Normal (8 - 12 hours) Abnormal Brush teeth w/fluoridated toothpaste Additional area for comments on page 2 Neck Child Development and Behavior Listen to and respect your child Lungs Screening and Procedures : Reinforce limits, be consistent Oral Health Risk Assessment Heart/pulses Daily/Bedtime Routine Subjective Hearing -Parental observation/ Begin toilet training when child is ready concerns Abdomen Hug, talk, read, and play together Subjective Vision -Parental observation/ Encourage self-expression, choices concerns Genitalia Praise good behavior and accomplishments Limit television/screen time Labs Spine Family Support and Relationships Standardized Developmental Screening Extremities/hips Encourage supervised play with other children Completed - don’t expect toddler to share Tool Used Neurological Help child express emotions RESULTS: No Risk At Risk Substance Abuse, Child Abuse, Domestic Abnormal Findings and Comments Violence Prevention, Depression Psychosocial/Behavioral Assessment Discuss child care, play groups, preschool, Y N early intervention programs, parenting (see additional note area on next page) Other Anticipatory Guidance Discussed: Screening for Abuse Y N Results of visit discussed with parent Y N

Immunizations: Plan Immunizations Reviewed, Given & Charted - History/Problem List/Meds Updated if not given, document rationale Fluoride Varnish Applied Next Well Check: 3 years of age Impactsis (OH registry) updated Referrals Help Me Grow WIC A standardized developmental screening test Children Special Health Care Needs should be administered (Medicaid required Influenza Other Transportation Dentist and AAP recommended) at the 30 month visit.

Acetaminophen mg. q. 4 hours Other Provider Signature Other

WELL CHILD EXAM - EARLY CHILDHOOD: 30 MONTHS

Date Patient Name DOB

Developmental Questions and Observations A standardized developmental screening test should be administered (Medicaid required and AAP recommended) at the 30 month visit.

Ask the parent to respond to the following statements about the child: Yes No Please tell me any concerns about the way your child is behaving or developing

My child likes to be with me. My child is interested in and is beginning to play with other children. My child smiles, laughs, protests and says, “No”. My child uses 3-4 word phrases. My child eats a variety of foods. My child can throw a ball overhand. My child can jump up and down in place.

Ask the parent to respond to the following statements: Yes No I have people who help me when I get frustrated with my child. I am enjoying my time with my child. I have time for myself, partner and friends. I feel safe with my partner.

Provider to follow up as necessary

Developmental Milestones Always ask parents if they have concerns about development or behavior. A standardized developmental screening test should be administered at the 30 month visit (Medicaid required and AAP recommended; Tool Used: ). In addition, the following should be observed: Child Develop ment Parent Development Understands two step verbal commands Yes No Appropriately disciplines child Yes No Imitates adults Yes No

Is understandable to others 50% of the time Yes No Positively talks, listens, and responds to Yes No Uses words to communicate with others Yes No child Points to 6 named body parts (nose, eyes, Yes No Parent is loving toward child Yes No ears, mouth, hands, feet, tummy, hair) Avoids eye contact and touch Yes No Uses words to tell child what is coming next Yes No Often fearful and irritable Yes No

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 30 Months Health Tips Milestones Are your child’s shots up to date? Ask your child’s doctor or nurse Ways your child is developing between 2 ½ and 3 years of age. about a flu shot for your child.

• Offer your child a variety of healthy foods every day. Limit junk May not want to do what parent wants; says, “NO” often foods. Eat meals together as a family as often as possible. Turn • Toilet trained during the daytime off the TV while eating together. • Shows feelings and is playful with others • Brush your child’s teeth at least once a day with a pea-sized Throws a ball overhand amount of fluoride toothpaste. • Rides a tricycle Each child develops in his own way, but you know your child best. • Knows name, age, and gender If you think he is not developing well, you can get a free • Able to leave parent or caregiver when in a known place screening. Call your child’s doctor or nurse with questions. • Plays with other children • Is able to feed and dress self Parenting Tips Take your child outside to play and help her play active games • Can draw a cross and a circle like catch, tag, and hide-and-seek. Give her simple toys to play • Plays “make believe” games with dolls and stuffed animals with, like blocks, crayons, paper, and stuffed animals.

For Help or More Information : Read to your child everyday. He may like books that tell about Safe Gun Storage Information: daily activities like playing, eating, and getting dressed. Your child Call 1-202-662-0600 or go to www.usa.safekids.org may like the same book to be read over and over.

Social Support Services: Encourage your child’s decision to use the potty, but don’t force or Contact the local county Department of Job and Family Services punish her if she isn’t ready. She may not be ready until about Healthchek Coordinator age 3. She’ll show you she’s ready by being dry after sleep and telling you when she wants to use the toilet. For help finding childcare: Bureau of Child Care and Development -800.886.3537 Don’t spank or yell at your child. Calmly, give your child http://www.odjfs.state.oh.us/cdc/query.asp something different to do. Use words to tell your child when he is doing something good. Help your child understand how he’s For information about lead screening: feeling by naming the feeling. Medicaid Consumer Hotline-800.324.8680 When you are a parent you will be happy, mad, sad, frustrated, Poison Prevention: angry and afraid, at times. This is normal. If you feel very mad or Call the Poison Control Center at 1-800-222-1222 frustrated: 1. Make sure your child is in a safe place and walk away. If you’re concerned about your child’s development: 2. Call a good friend to talk about what you are feeling. Contact Help Me Grow at 1-800-755-GROW (4769) or at 3. Call Cooperative Extension for classes-614. 688.5378 www.ohiohelpmegrow.org/ . 4. Call 800.448.3000 or visit Boystown Parenting Hotline at (http://www.parenting.org/hotline/index.asp ) They will not Parenting skills or support: ask your name, and can offer helpful support and guidance. Call Cooperative Extension for classes-614. 688.5378 The helpline is open 24 hours a day.

Support for families of children with special health care needs: Safety Tips Bureau for Children with Medical Handicaps, ODH ° Keep cleaning supplies and medicine locked up and out of 1-800-755-4769 (Parents).Visit the Website at: reach http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx ° Always hold your child’s hand while walking near traffic, including in parking lots. Check behind your car before backing Domestic Violence hotline: up in case a child is behind it. National Domestic Violence Hotline - (800) 799-SAFE (7233) or ° If you have guns at home, keep them unloaded and locked online at www.ndvh.org ° Put a life jacket on your child whenever she is near the water or in a boat. Always watch her around the water ° Keep matches and lighters out of reach

Date Ohio Department of Medicaid WELL CHILD EXAM - EARLY CHILDHOOD: 3 YEAR Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaint(s)

Weight Percentile Length Percentile BMI Percentile BP Temp. Pulse Resp.

% % %

Interval History: Patient Unclothed Y N Anticipatory Guidance/Health Education (Include injury/illness, visits to other health care (X if discussed) providers, changes in family or home) Review of Physical Safety Systems Exam Systems Teach child to wash hands, wipe nose N A N A w/tissue General Appearance Reinforce bedtime routine Nutrition Fires/Burns/test smoke alarms Grains servings per day Skin/nodes Appropriate car seat placed in back seat Fruit/Vegetables servings per day Head Use bike helmet Whole Milk servings per day Teach stranger safety Meat/Beans servings per day Eyes Childproof home - (matches, guns, City water Well water Bottled water medicines) WIC Y N Ears Supervise play, ensure playground safety Elimination Normal Abnormal Exercise Assessment Nose Nutrition/physical activity Physical Activity: minutes per day Sleep Physical activity in a safe environment Oropharynx Normal (8 - 12 hours) Abnormal Family physical activity Additional area for comments on page 2 Gums/palate Limit screen time to 1-2 hours per day Offer variety of healthy foods Screening and Procedures: Neck Oral Health Oral Health Risk Assessment Lungs Schedule dental appointment Subjective Hearing -Parental observation/ Teach child to brush teeth concerns Heart/pulses Vision Visual acuity Child Development and Behavior R L Both Abdomen Reinforce limits, provide choices Parental observation/concerns Encourage talking and reading Developmental Surveillance Genitalia Encourage safe exploration Social-Emotional Communicative Help child cope with fears Spine Cognitive Physical Development Family Support and Relationships Psychosocial/Behavioral Assessment Extremities/hips Show affection, spend time with each child Y N Create family time together Screening for Abuse Y N Neurological Praise good behavior and accomplishments If Risk : Substance Abuse, Child Abuse, Domestic IPPD (result) Abnormal Findings and Comments Violence Prevention Hct or Hgb (result) Handle anger constructively, help siblings If not previously tested: (see additional note area on next page) resolve conflicts Lead level mcg/dl (required for Results of visit discussed with parent Y N Make time for self, partner, friends Medicaid Choose responsible caregivers Labs Plan Discuss community programs, preschool, Immunizations: History/Problem List/Meds Updated Referrals head start, parenting groups Immunizations Reviewed, Given & Charted WIC Head Start` - if not given, document rationale Next Well Check: 4 years of age Children Special Health Care Needs (Refer to AAP Guidelines) Transportation Dentist Developmental Questions and Observations Impactsiis (OH registry) updated on Page 2 Other Provider Signature Influenza Other Other Acetaminophen mg. q. 4 hours

WELL CHILD EXAM - EARLY CHILDHOOD: 3 YEARS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the child: Yes No Please tell me any concerns about the way your child is behaving or developing

My child is able to play by him/herself for short periods of time. My child is able to leave me when in a known place. My child enjoys playing with other children. My child can tell when others are happy, mad or sad. My child can copy a circle. My child eats a variety of foods. My child knows his/her name, age and sex. My child can jump off a step with both feet.

Ask the parent to respond to the following statements: Yes No I have people who assist me when I have questions or need help. I am enjoying my time with my child. I have time for myself, partner and friends. I feel safe with my partner. I feel confident in parenting.

Provider to follow up as necessary

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 3 Years Health Tips Milestones Your child still needs about two cups of milk every day. Offer a Ways your child is developing between 3 and 4 years of age. variety of fruits and vegetables daily. Water is a healthy drink so offer it instead of sweetened drinks. • Can sing a song from memory Help your child brush his teeth every day with a pea-sized amount • Learning to share of fluoride toothpaste. Make sure he gets a dental checkup once a • Talks about what he did during the day year. • Enjoys playing “pretend” and listening to stories • Can hop, jump on one foot Teach your child to wash her hands well after playing, after using the toilet, and before eating. Use soap and rub hands together for • Rides a tricycle or a bicycle with training wheels about 20 seconds. • Knows her first and last name • Names 4 colors Each child develops in his own way, but you know your child best. • Begins to test limits If you think he is not developing well, call your child’s doctor or nurse and tell them your concerns. • Shows a silly sense of humor

• Throws a ball overhand Parenting Tips • Plays board games or card games Your child learns best by doing. She needs to: • Draws a person with 3 parts (such as head, body, legs) • Play active games (tag, ball, riding wheeled toys, climbing) • Builds towers of 9-10 blocks • Play imagination games (using dolls, toys, story books) • Play with toys that uses her hands (blocks, big puzzles) For Help or More Information: • Limit television and computer time to 1-2 hours a day Safe Gun Storage Information: Call 1-202-662-0600 or go to www.usa.safekids.org Help your child feel good about himself and others: • Praise your child every day For help finding childcare: • Be consistent and clear about your child’s behaviors that are Bureau of Child Care and Development -800.886.3537 okay or not okay http://www.odjfs.state.oh.us/cdc/query.asp • Use discipline to teach and protect your child, not to punish him Car seat safety: or make him feel bad about himself Contact the Auto Safety Hotline at 1-888-327-4236 or online at • Help your child "use his words" when having a disagreement www.nhtsa.dot.gov instead of hitting, kicking, or biting When you are a parent you will be happy, mad, sad, frustrated, For information about lead screening: angry and afraid, at times. This is normal. If you feel very mad or Medicaid Consumer Hotline-800.324.8680 frustrated: 1. Put your child in a safe place and walk away. Social Support Services: 2. Call a friend or your partner. It can help to talk about what you Contact the local county Department of Job and Family Services are feeling. Healthchek Coordinator 3. Call Cooperative Extension for classes-614. 688.5378 4. Call 800.448.3000 or visit Boystown Parenting Hotline at Poison Prevention: (http://www.parenting.org/hotline/index.asp ). They will not Call the Poison Control Center at 1-800-222-1222 ask your name, and can offer helpful support and guidance.

For information if you’re concerned about your child’s The helpline is open 24 hours a day. development: Contact Help Me Grow at 1-800-755-GROW (4769) or at Safety Tips Check your home for dangers often. Your child is not old enough www.ohiohelpmegrow.org/ . to stay away from things that could harm her, like matches, guns, and poisons. Lock those things up! Parenting skills or support: Call Cooperative Extension for classes-614. 688.5378 Continue using a car seat until your child weighs 40 pounds or around age 4. After that, use a booster seat until your child is 4’9” Domestic Violence hotline: or age 8. Keep your child in the back seat. National Domestic Violence Hotline - (800) 799-SAFE (7233) or online at www.ndvh.org Make sure your child uses a helmet whenever he rides a tricycle, scooter, or other toys with wheels.

Ohio Department of Medicaid Date

WELL CHILD EXAM - EARLY CHILDHOOD: 4 YEAR Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaint(s)

Weight Percentile Length Percentile BMI Percentile BP Temp. Pulse Resp. % % %

Interval History: Patient Unclothed Y N Anticipatory Guidance/Health Education (Include injury/illness, visits to other health care (X if discussed) providers, changes in family or home) Review of Physical Systems Exam Systems Safety N A N A Appropriate car seat placed in back seat General Smoke-free Home and car /smoke alarms Appearance Nutrition Use bike helmet Grains servings per day Skin/nodes Teach stranger/pedestrian/playground safety Fruit/Vegetables servings per day & supervise child when outdoors Whole Milk servings per day Head Childproof home - (matches, poisons, Meat/Beans servings per day cigarettes, cleaners, medicines, knives) Eyes City water Well water Bottled water Gun safety WIC Y N Ears Nutrition/physical activity Elimination Normal Abnormal Physical activity in a safe environment Exercise Assessment Nose Family physical activity Physical Activity: minutes per day Oropharynx Limit screen time to 1-2 hours per day Sleep Offer variety of healthy foods Normal (8 - 12 hours) Abnormal Gums/palate Eat meals as a family Additional area for comments on page 2 Screening and Procedures: Neck Child Development and Behavior Hearing Screening audiometry Supervise tooth brushing Lungs Parental observation/concerns Reinforce limits, provide choices Encourage child to talk about feelings Vision Visual acuity Heart/pulses R L Both Create a bedtime ritual that includes reading Parental observation/concerns Abdomen or calmly talking with your child Developmental Surveillance Simple household tasks & responsibilities Social-Emotional Communicative Genitalia Praise good behavior and accomplishments Cognitive Physical Development Spine Family Support and Relationships Psychosocial/Behavioral Assessment Use correct terms for all body parts. Y N Extremities/hips Explain good touch/bad touch and that certain Screening for Abuse Y N body parts are private If Risk: Neurological Listen/respect/show interest in activities IPPD (result) Substance Abuse, Child Abuse, Domestic Hct or Hgb (result) Abnormal Findings and Comments Violence Prevention, Depression Dyslipidemia (result) Discuss community programs, preschool, If not previously tested: (see additional note area on next page) head start, parenting groups, after school child Lead level mcg/dl (required for care Medicaid) Results of visit discussed with parent Y N

Labs Plan History/Problem List/Meds Updated Immunizations: Referrals Next Well Check: 5 years of age Immunizations Reviewed, Given & Charted - WIC Head Start Help Me Grow Developmental Questions and Observations if not given, document rationale Children Special Health Care Needs on Page 2 (Refer to AAP Guidelines) Transportation Dentist Provider Signature Impactsis (OH registry) updated Other

Influenza Other Other Acetaminophen mg. q. 4 hours

WELL CHILD EXAM - EARLY CHILDHOOD: 4 YEARS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the child: Yes No Please tell me any concerns about the way your child is behaving or developing

My child is learning how to play and share with others. My child says positive things about themselves. My child can tell when others are happy, mad or sad. My child enjoys pretend play. My child eats a variety of foods. My child can sing a song. My child can hop on one foot.

Provider to follow up as necessary

Developmental Milestones Always ask parents if they have concerns about development or behavior. (You may use the following screening list, or a standardized developmental instrument or screening tool. Tool Used: ). Child Development Parent Development Dresses self Yes No Appropriately disciplines child Yes No Balances on each foot for 2 seconds Yes No Parent is loving toward child Yes No Positively talks, listens, and responds to Says first and last name when asked Yes No Yes No child. Parent uses words to tell child what is Can draw a person with three parts Yes No Yes No coming next Aggressive or destructive behavior that threatens, harms or damages people, Yes No animals or property Displays negativity, low self-esteem, or Yes No extreme dependence Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 4 Years Health Tips Milestones Your child will need some shots before starting school. Make sure Ways your Child is developing between 4 and 5 years of age. you get them soon.

• Counts on fingers and knows some letters Be a role model for your child. Teach your child healthy habits by eating healthy foods, limiting screen time (T.V., computers, video • Talks about what will happen tomorrow and what happened games) and encouraging family physical activity. yesterday

• May begin to skip Help your child get enough sleep so she will be happier and will • May have special friends and may tease or ignore some learn easier! Put her to bed early so she gets 10 to12 hours of children sleep at night. Have a bedtime routine to calm your child before • Begins to know the difference between right and wrong and going to sleep. Read a story or talk together before bed. telling the truth and lying Each child develops in his own way, but you know your child best. • May want to be “just like you” and may want to share in the If you think he is not developing well, call your child’s doctor or things you do nurse and tell them your concerns. • Uses words to solve simple problems and say what they’re feeling Parenting Tips • Plays dress-up and make believe with other children Help your child know what to expect by making a calendar of pictures to show her activities for the day. For Help or More Information: Safety information: Your child learns best by doing. He needs to: Call 1-202-662-0600 or go to www.usa.safekids.org ° Play active games (tag, ball, riding toys, climbing) ° Play board games and do puzzles Car seat safety: Contact the Auto Safety Hotline at 1-888-327-4236 or online at Limit television and computer time to 1 - 2 hours a day. www.nhtsa.dot.gov To locate a Child Safety Seat Inspection Station, call 1-866- Help your child feel good about herself and others: SEATCHECK (866-732-8243) or online at www.seatcheck.org ° Praise your child every day ° Be clear about behaviors that are okay or not okay Social Support Services: ° Help your child use words when she is feeling upset instead of hitting, kicking, biting or saying mean things Contact the local county Department of Job and Family Services ° Talk to your child about why teasing other children is wrong Healthchek Coordinator and what she should do instead

For help finding childcare: If you feel very mad or frustrated with your child: Bureau of Child Care and Development -800.886.3537 1. Make sure your child is in a safe place and walk away. http://www.odjfs.state.oh.us/cdc/query.asp 2. Call a friend to talk about what you are feeling. 3. Call Cooperative Extension for classes-614. 688.5378 For information about lead screening: 4. Call 800.448.3000 or visit Boystown Parenting Hotline at Medicaid Consumer Hotline-800.324.8680 (http://www.parenting.org/hotline/index.asp ). They will not ask Poison Prevention: your name, and can offer helpful support and guidance. The Call the Poison Control Center at 1-800-222-1222 helpline is open 24 hours a day.

For information if you’re concerned about your child’s Safety Tips development: Booster car seats are for big kids! Use a booster in the back seat Contact Help Me Grow at 1-800-755-GROW (4769) or at with lap/shoulder belts. www.ohiohelpmegrow.org/ . Make sure your child knows his address and phone number. Parenting skills or support: Teach him how to call 911 in an emergency and to stay on the line Call Cooperative Extension for classes-614. 688.5378 if he has to call for help. Practice with a toy phone.

Domestic Violence hotline: Teach your child to stop, drop, and roll on the ground if her clothes National Domestic Violence Hotline - (800) 799-SAFE (7233) or catch on fire. online at www.ndvh.org

For help teaching your child about fire safety: Talk with firefighters at your local fire station

Ohio Department of Medicaid Date

WELL CHILD EXAM - EARLY CHILDHOOD: 5 YEAR Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History Chief Complaint(s)

Weight Percentile Length Percentile BMI Percentile Temp. Pulse Resp. BP % % % Interval History : Anticipatory Guidance/Health Education (Include injury/illness, visits to other health Patient Unclothed Y N (X if discussed) care providers, changes in family or home) Review of Physical Safety Systems Exam Systems Teach child to wash hands, wipe nose N A N A w/tissue General Nutrition Appearance Working smoke detectors/fire escape plan Grains servings per day Appropriate booster seat placed in back seat Skin/nodes Fruit/Vegetables servings per day Carbon monoxide detectors/alarms Whole Milk servings per day Head Pool/tub/water safety - swimming lessons Meat/Beans servings per day Use bike/skating helmet City water Well water Bottled Eyes Supervise near pets, mowers, driveways, water streets Ears Elimination Normal Abnormal Gun safety Childproof home - (matches, poisons, Exercise Assessment Nose Physical Activity minutes per day cigarettes, cleaners, medicines, knives) Sleep Oropharynx Nutrition/physical activity Normal (8 - 12 hours) Abnormal Provide a healthy breakfast every morning Additional area for comments on page 2 Gums/palate Family meals Screening and Procedures: Offer variety of healthy foods and include 5 Neck Urinalysis (Required for Medicaid) servings of fruits & veggies every day Lungs Limit TV, video, and computer games Hearing Screening audiometry Physical activity & adequate sleep Parental observation/concerns Heart/pulses Oral Health Vision Visual acuity Schedule dental appointment Abdomen R L Both Supervise tooth brushing Parental observation/concerns Genitalia Discuss flossing, fluoride, sealants Child Development and Behavior Developmental Surveillance Spine Establish routines and traditions Social-Emotional Communicative Explain good touch/bad touch and that Cognitive Physical Development Extremities/ hips certain body parts are private Psychosocial/Behavioral Assessment Reinforce limits, provide choices Neurological Y N Simple household tasks & responsibilities Screening for Abuse Y N Abnormal Findings and Comments Praise good behavior and actions If Risk: Family Rules/Respect/Right from wrong IPPD (result) Encourage expression of feelings Hct or Hgb (result) (see additional note area on next page) Family Support and Relationship If not previously tested: Results of visit discussed with parent Y N Listen/respect/show interest in activities Lead level mcg/dl (required for Substance Abuse, Child Abuse, Domestic Plan Medicaid) Violence Prevention, Depression History/Problem List/Meds Updated Labs Discuss community and recreational Immunizations: Referrals programs, school, and after school care Immunizations Reviewed, Given & Charted Children Special Health Care Needs Volunteer and become involved with school - if not given, document rationale Transportation Help Me Grow Meet your child’s school teachers Next Well Check: 6 years of age (Refer to AAP Guidelines) Dentist Developmental Questions and Observations Impactsis (OH registry) updated Other on Page 2 Acetaminophen mg. q. 4 hours Other Provider Signature

WELL CHILD EXAM - EARLY CHILDHOOD: 5 YEARS

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the child: Yes No Please tell me any concerns about the way your child is behaving or developing

My child does what I ask them to do most of the time. My child says positive things about themselves. My child shows an ability to understand the feelings of others. My child can tell a story using full sentences. My child follows simple directions. My child can recognize most letters and is able to print some letters. My child can balance on one foot.

Ask the parent to respond to the following statements: Yes No I have people I can turn to when I have questions or need help. I feel good about my child starting school. I am sad more often than I am happy. I feel confident in parenting.

Provider to follow up as necessary

Developmental Milestones Always ask parents if they have concerns about development or behavior. (You may use the following screening list, or a standardized developmental instrument or screening tool. Tool Used ). Child Development Parent Development Dresses without supervision Yes No Appropriately disciplines child Yes No Skips and hops Yes No Parent is loving toward child Yes No Draws a person with head, body, arms and Positively talks, listens, and responds to Yes No Yes No legs child. Appears unusually fearful, anxious or Parent uses words to tell child what is Yes No Yes No withdrawn coming next Aggressive or destructive behavior that Parent encourages child to speak for him or threatens harms or damages people, animals Yes No Yes No her self, share ideas, wants and needs. or property Displays negativity, low self-esteem, or Yes No extreme dependence Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 5 Years Parenting Tips Milestones Eat together as often as possible. Turn off the TV and the phone, Ways your child is developing between 5 and 6 years of age. and enjoy each other.

• Recognizes her own printed name Listen when your child talks to you. Look at him and pay attention. Then answer or ask about his ideas. Let him know that what he • May form special groups of friends and may be jealous of thinks and says is important to you. others

• Takes turns Talk with your child about how to avoid sexual abuse. Teach your • Feels proud of himself and his accomplishments child about privacy and teach that adults shouldn’t ask her to keep • Helps with family chores secrets from you or show their private parts or ask to see your child’s private parts. Tell your child she should say “no” and that • Able to follow rules at home and school and respect authority she should tell you if anyone tries to harm her. • Beginning to learn rules for simple games • Riding a bicycle and learning to swim Limit TV or computer time so your child also has time for books and active play. Read storybooks with him daily. Take your child For Help or More Information: outside often to play. Social Support Services: Contact the local county Department of Job and Family Services Help your child feel good about herself and others: ° Praise your child every day Healthchek Coordinator ° Be clear about behaviors that are okay or not okay

° Help your child use words when she is feeling upset instead of Child sexual abuse, physical abuse, information and support: hitting, kicking, biting or saying mean things • Childhelp National Child Abuse Hotline1-800-4-A-CHILD (1-800- ° Talk to your child about why teasing other children is wrong 422-4453) or online at www.childhelp.org and what she should do instead

Domestic Violence hotline: If you feel very mad or frustrated with your child: National Domestic Violence Hotline - (800) 799-SAFE (7233) or 1. Make sure your child is in a safe place and walk away. online at www.ndvh.org 2. Call a friend to talk about what you are feeling. 3. Call Cooperative Extension for classes-614. 688.5378 Safe Gun Storage Information: 4. Call 800.448.3000 or visit Boystown Parenting Hotline at Call 1-202-662-0600 or go to www.safekids.org . (http://www.parenting.org/hotline/index.asp ). They will not ask your name, and can offer helpful support and guidance. The Poison Prevention: helpline is open 24 hours a day. Call the Poison Control Center at 1-800-222-1222 Safety Tips Parenting skills or support: Booster car seats are for big kids! Use a booster in the back seat Call Cooperative Extension for classes-614. 688.5378 with lap/shoulder belts.

For help teaching your child about fire safety: Your child should always wear a lifejacket around water, even after Talk with firefighters at your local fire station he has learned to swim.

Health Tips Always watch your child closely when she is near the street. Continue to take your child for a check-up each year with a doctor Children are not ready to ride bikes safely on streets or cross or nurse. streets without an adult until they reach at least age 9. Your child is not old enough to always behave safely around vehicles. Your child will still need you to help get all of her teeth brushed well. Make sure to take her for a dental check-up at least once a Teach your child to never touch a gun. If he finds one, he should year. tell an adult right away. Make sure any guns in your home are unloaded and locked up.

Ohio Department of Medicaid Date

WELL CHILD EXAM - MIDDLE CHILDHOOD: 6 - 10 YEAR Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History of Illness and Disease Chief Complaint(s)

Weight Percentile Length Percentile BMI Percentile Temp. Pulse Resp. BP % % % Interval History : Anticipatory Guidance/Health Education (Include injury/illness, visits to other health care Patient Unclothed Y N (X if discussed) providers, changes in family or home) Review of Physical Safety Systems Exam Systems Discuss avoiding alcohol, tobacco, drugs N A N A Monitor TV viewing & computer games General Appearance Booster seat/seat belt use in back seat Nutrition Keep home and car smoke-free Grains servings per day Skin/nodes Teach outdoor, bike, and water safety Fruit/Vegetables servings per day Head Use bike helmet/protective sporting gear Whole Milk servings per day Teach stranger and home safety Meat/Beans servings per day Eyes Gun safety City water Well water Bottled water Nutrition/physical activity Ears Elimination Normal Abnormal Limit sugar and high fat food/drinks Regular family meals Exercise Assessment Nose Offer variety of healthy foods and include 5 Physical Activity minutes per day Oropharynx servings of fruits & veggies every day Sleep Limit TV, video, and computer games Normal (8 - 12 hours) Abnormal Gums/palate Physical activity & adequate sleep Additional area for comments on page 2 Oral Health Neck Schedule dental appointment Screening and Procedures: Lungs Discuss flossing, fluoride, sealants Hearing Screening audiometry Child Development and Behavior Parental observation/concerns Heart/pulses Encourage independence Vision Visual acuity Answer questions about puberty simply Abdomen R L Both Consistently reinforce limits & family rules Parental observation/concerns Genitalia Praise child and encourage child to talk about Dental Oral Health Risk Assessment feelings, school, and friends Spine Supervise child’s activities Developmental Surveillance Assign household tasks & responsibilities Social-Emotional Communicative Extremities/hips Family Support and Relationships Cognitive Physical Development Listen/show interest in child’s activities Neurological Psychosocial/Behavioral Assessment Spend family time together Y N Normal Growth and Development Set reasonable but challenging goals Screening for Abuse Y N Tanner Stage Encourage positive interaction with siblings, If Risk: Abnormal Findings and Comments teachers and friends IPPD (result) Offer constructive ways to handle family Hct or Hgb (result) conflict and anger; don’t allow violence Dyslipidemia (result) (see additional note area on next page) Know child’s friends and their families If not previously tested: Results of visit discussed with parent Y N Be a positive role model for your child Lead level mcg/dl Substance Abuse, Child Abuse, Domestic Sickle Cell (result) Plan Violence Prevention, Depression History/Problem List/Meds Updated Ensure safe, supervised after school care Immunizations: Referrals Next Well Check: ______years of age Immunizations Reviewed, Given & Charted Children Special Health Care Needs (according to AAP.org guidelines) Dental Transportation Developmental Questions and Observations If needed but not given, document rationale Other on Page 2 Impactsiis (OH registry) updated Other Provider Signature

WELL CHILD EXAM - MIDDLE CHILDHOOD: 6 - 10 Year

Date Patient Name DOB

Developmental Questions and Observations

Ask the parent to respond to the following statements about the child: Yes No Please tell me any concerns about the way your child is behaving or developing:

My child has hobbies or interests that he/she enjoys. My child follows rules in home, school and the community, most of the time. My child’s behavior, relationships and school performance are appropriate most of the time. My child handles stress, anger, frustration well, most of the time. My child eats breakfast every day. My child is doing well in school. My child talks to me about school, friends and feelings. My child seems rested when he/she wakes up. My child gets some physical activity every day.

Ask the parent to respond to the following statements: Yes No I know what to do when I am frustrated with my child. I enjoy seeing my child become more independent and self-reliant. Our family has experienced major stresses and/or changes since our last visit. It is harder for me everyday to do what my child needs because of the sadness that I feel.

Ask the child to respond to the following statements: Yes No I feel good about my friends and school. I know what to do when another child or adult tries to bully me or hurt me.

Provider to follow up as necessary

Developmental Milestones Always ask parents if they have concerns about development or behavior. (You may use the following screening list, or a standardized developmental instrument or screening tool. Tool Used ). Child Development States phone number and home address Yes No Reading and math are at grade level Yes No Has close friend(s) Yes No Child communicates/expresses self Yes No Child responds to parent and health care Yes No provider Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 6 - 10 Years Parenting Tips Milestones Praise your child when he works hard and finishes things. Ways your Child is developing between 6 and 10 years of age. • Your child should continue to loose baby teeth and get permanent Most children learn by watching and then doing. Show and tell teeth your child how to do a job. Then have her do it while you watch. Tell her what she did right first, and then what she needs to do • Some girls’ breasts will begin to grow between 8 and 10 years of differently. age. Talk with her about her growing body as this starts to happen

• Eight year olds can make their own bed, set the table and bathe Talk about why children should not use drugs and alcohol. Set themselves a good example for your child. • You help your child learn new skills by talking and playing with them. Make a game of practicing hand signals or saying “No” Teach your child what to do and not do when they’re angry. when a stranger offers them a ride • Your child will keep growing more independent Make sure your computer is in a room where you can watch your child’s use of the internet. For Help or More Information: Child sexual abuse, physical abuse, information and support: Set limits and tell your child what will happen if he doesn’t follow rules. • Rape, Abuse, and Incest National Network at 1-800-656-HOPE

(4673) Teach your child how to deal with peer pressure. • State of Ohio Child Protection: 866-635-3748 • Childhelp National Child Abuse Hotline1-800-4-A-CHILD (1-800- Encourage your child to join community groups, team sports, 422-4453) or online at www.childhelp.org school clubs and other activities.

Social Support Services: If you feel very mad or frustrated with your child: Contact the local county Department of Job and Family Services 1. Make sure your child is in a safe place and walk away. 2. Call a friend to talk about what you are feeling. Healthchek Coordinator 4. Call the Cooperative Extension for classes-614. 688.5378 Domestic Violence hotline: 3. Call the free Boystown Parenting Hotline- 800.448.3000 National Domestic Violence Hotline - (800) 799-SAFE (7233) or They will not ask your name, and can offer helpful support online at www.ndvh.org and guidance. The helpline is open 24 hours a day.

Safe Gun Storage Information: Safety Tips Call 1-202-662-0600 or go to www.safekids.org Make sure that everyone who rides in the car with you wears their seat belt. Help your child know how to ask to use a seat Parenting skills or support: belt or booster when he rides with other drivers.

Cooperative Extension for classes-614. 688.5378 Practice family safety in your house: test the smoke alarm and Boystown Parenting Hotline- 800.448.3000 or website visit at change the batteries when needed; have fire drills and practice (http://www.parenting.org/hotline/index.asp ) fire escape plan.

For help teaching your child about fire safety: Your child should always wear a lifejacket around water, even Talk with firefighters at your local fire station after she has learned to swim.

Children’s Mental Health parent support and advocacy: Make sure your child wears a helmet when using bikes, skates, Contact Ohio Department of Mental Health 1-877-275-6364 inline skates, scooters, and skateboards. Practice safe walking and bike riding. Children are not ready to ride bikes safely on Health Tips streets or cross streets without an adult until they reach at least Your child will still need you to help get all of their teeth brushed well. age 9. Make sure to take your child for a dental check-up at least once a year. Ask about dental sealants. Teach your child to never touch a gun. If your child finds one, she should tell an adult right away. Make sure any guns in your You and your child should be physically active at least 60 minutes home are unloaded and locked up. each day. It doesn’t have to be all at once. Find activities that you and your child enjoy. This is an important habit for your child to learn.

Keep healthy snacks available. Your child needs fruit, vegetables, juice, and whole grains for growth and energy.

Ohio Department of Medicaid Date WELL CHILD EXAM - Early Adolescence: 11 - 14 Year Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History of Illness and Disease Chief Complaint(s)

Weight Percentile Length Percentile BMI Percentile Temp. Pulse Resp. BP

% % % Interval History : Patient Unclothed Y N Anticipatory Guidance/Health Education (Include injury/illness, visits to other health (X if discussed) care providers, changes in family or home) Review of Physical Safety Systems Exam Systems Avoid alcohol, tobacco, drugs, inhalants N A N A Make a plan with child if in unsafe situation General Appearance Seat belt use Nutrition Swimming/Water Safety Skin/nodes Grains servings per day Use bike helmet/protective sporting gear Fruit/Vegetables servings per day Head Gun and weapon safety Whole Milk servings per day Nutrition/physical activity Meat/Beans servings per day Eyes Limit sugar and high fat food/drinks City water Well water Bottled Healthy weight Ears water Offer variety of healthy foods and include 5 Elimination Normal Abnormal Nose servings of fruits & veggies every day Exercise Assessment Limit TV, video, and computer games Physical Activity: minutes per day Oropharynx Physical activity & adequate sleep Sleep Normal Abnormal Eat meals as a family Reproductive Gums/palate Oral Health Menstrual Schedule dental appointment Premenarchal Normal Abnormal Neck Breast Exam/Palpation Brush and floss teeth Normal Abnormal Lungs Limit sweets/soda Sexual Activity Y N Child Development and Behavior Contraceptive Method used Heart/pulses Discuss puberty, development, contraception, Additional area for comments on page 2 STDs Abdomen Screening and Procedures: Normal sexual feelings/delaying sex Hearing Screening audiometry Genitalia Peer relationships Parental observation/concerns Discuss family & household responsibilities Vision Visual acuity Spine Discuss ways to handle anger/conflict R L Both How to handle stress & disappointment Extremities/hips Parental observation/concerns Family Support and Relationships Substance Abuse, Child Abuse, Domestic Dental Oral Health Risk Assessment Neurological Developmental Surveillance Violence Prevention, Depression Social-Emotional Communicative Normal Growth and Development Know child’s friends and their families Cognitive Physical Development Tanner Stage Spend family time together Psychosocial/Behavioral Assessment Alcohol & Drug Use (risk assessment) Encourage positive interaction with siblings, Y N Y N teachers, friends and you Screening for Abuse Y N Abnormal Findings and Comments Discuss limits and consequences If Risk: Home, school, community rules

IPPD (result) Discuss school transitions & ability to adapt (see additional note area on next page) Hct or Hgb (result) Encourage participation with peer activities Results of visit discussed with child/parent Dyslipidemia (result) Encourage to volunteer/participate with STI Screening (result) Y N religious, school or community activities Cervical Dysplasia (result) Plan Next Well Check ______years of age Sickle Cell (if not previously tested) History/Problem List/Meds Updated (result) Developmental Questions and Observations Immunizations: Referrals Transportation on Page 2

Immunizations Reviewed, Given & Children Special Health Care Needs Provider Signature Charted (according to AAP.org guidelines) Dental Other If needed but not given, document rationale Impactsiis (OH registry) updated

WELL CHILD EXAM - Early Adolescence: 11 - 14 Years

Date Patient Name DOB

Developmental Questions and Observations You may use the following screening list, or an age appropriate standardized developmental instrument or screening tool.*

Ask the parent to respond to the following statements about the child: Yes No Please tell me any concerns about the way your child is behaving or developing

My child eats breakfast everyday. My child is doing well in school. My child has one or more close friends. My child handles stress, anger, frustration well, most of the time. My child seems rested when he/she awakens. My child enjoys at least one activity and/or interest. My child joins in family activities. My child’s activities are supervised by adults I trust.

Ask the parent to respond to the following statements: Yes No I am proud of my child. I talk to my child about alcohol, drugs, smoking and sex.

Ask the child to respond to the following statements: Yes No I feel good about my friends and school. I know what to do when I feel angry, stressed or frustrated. I enjoy school

*Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. ( Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents )

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

Your Child’s Health at 11 - 14 Years Health Tips Milestones Growth happens at different times for everyone. This can worry a Ways your child is developing between 11 and 14 years of age. child. If your child has not begun to have growth changes by age • Most children get their second molars (back teeth) between 12 14 talk with the doctor. and 13. Talk with your dentist about sealants. Your child should floss daily. Your child will need shots at this age. Talk with your child’s doctor and make sure your child has had all of her shots. • Between the ages of 10 and 14 many girls will begin to grow

breasts and pubic hair and begin their periods. Your child should have a goal to be physically active at least 60 • Between 10 and 14 many boys will begin to grow pubic hair and minutes each day. It doesn’t have to be all at once. Find activities they may notice their scrotum and penis begin to change. Their that you and your child enjoy. This is an important habit for your voice may change and they may start to grow facial hair. child to learn. • Many boys and girls will have a growth spurt sometime between 10 and 15. It is important that your child eat healthy foods and snacks. Keep • Your child may have a hard time making good choices and may healthy snacks available. Your child needs fruit, vegetables, juice, feel pushed to make bad choices so they feel like they fit in with and whole grains for growth and energy. kids at school. Parenting Tips For Help or More Information: Talk with your child about the changes in her body before and as Social Support Services: the changes happen. Tell her these are signs of growing up and it can be exciting but can also be scary. Contact the local county Department of Job and Family Services

Healthchek Coordinator Your child may be more emotional and sometimes rude or angry. Sometimes he feels sad, nervous or worried and things may not be Firearm safety: going right. Talk with your child about his feelings. Help him find a Call 1-202-662-0600 or go to www.safekids.org counselor if needed.

Domestic Violence hotline: Talk with and let your child know that sexual feelings are normal, National Domestic Violence Hotline - (800) 799-SAFE (7233) or but to delay having sex. online at www.ndvh.org Your child is growing mentally. You can help her thinking skills by Child sexual abuse, physical abuse, information and support: asking her to solve problems. • Rape, Abuse, and Incest National Network at 1-800-656-HOPE (4673) Talk about why teenagers should not use drugs and alcohol. Set a • State of Ohio Child Protection: 866-635-3748 good example for your child.

• Childhelp National Child Abuse Hotline1-800-4-A-CHILD (1-800- Teach your child how to deal with peer pressure. 422-4453) or online at www.childhelp.org

Encourage your child to join school or sporting activities. Information for teens and their parents:

Provides information for teens and parents of teen on many teen Safety Tips topics. http://www.kidshealth.org/ Cigarettes, drugs and alcohol are often offered to teenagers.

Practice “saying no” with your child. Sexuality Information for teens: ® (Planned Parenthood Federation of America) www.teenwire.com Teach your child gun safety. If you keep guns or rifles in your

home, make sure they are unloaded and locked up. Children’s Mental Health parent support and advocacy:

Contact Ohio Department of Mental Health 1-877-275-6364 Teach your child to walk away if they see someone with a gun or

other weapon and then report it to an adult they trust. Churches or schools in your area may give classes on how to handle conflicts and/or anger. These can be useful skills for young Teach your child to always wear a seatbelt in the car and to sit in teenagers. the back seat until they are adult height and weight.

It's important for your child to use the correct sports equipment and safety gear. Make sure it fits your child well.

Ohio Department of Medicaid Date WELL CHILD EXAM - Adolescence: 15 - 20 YEAR Patient Name DOB Sex Parent Name

Allergies Current Medications

Prenatal/Family History of Illness and Disease Chief Complaint(s)

Weight Percentile Length Percentile BMI Percentile Temp. Pulse Resp. BP

% % % Interval History: Patient Unclothed Y N Anticipatory Guidance/Health Education (Include injury/illness, visits to other health care Review of Physical (X if discussed) providers, changes in family or home) Systems Exam Systems Safety

N A N A Avoid alcohol, tobacco, drugs, inhalants

General Make a plan if in unsafe situation Appearance Nutrition Seat belt use for self and passengers Skin/nodes Grains servings per day Responsible Driving/follow speed limits Fruit/Vegetables servings per day Swimming/Water Safety Head Whole Milk servings per day Use bike helmet/protective sporting gear Gun and weapon safety Meat/Beans servings per day Eyes City water Well water Bottled water Learn to protect self from abuse Elimination Normal Abnormal Ears Limit time in sun-use sunscreen Exercise Assessment Nutrition/physical activity Nose Physical Activity minutes per day Healthy Weight/body image/dieting Limit TV, video, and computer games Sleep Normal Abnormal Oropharynx Reproductive Physical activity & adequate sleep Menstrual Gums/palate Eat meals as a family Premenarchal Normal Abnormal Oral Health Neck Breast Exam/Palpation Schedule dental appointment Brush and floss teeth Normal Abnormal Lungs Sexual Activity Y N No smoking/chewing tobacco Contraceptive Method used Heart/pulses Development and Behavior Increased responsibility for own health care Screening and Procedures: Abdomen Self Breast/Testicular Exam Hearing Screening audiometry Handling stress & disappointment Genitalia Parental observation/concerns Discuss development Normal sexual feelings Vision Visual acuity Spine R L Both Preventing pregnancy and STIs Parental observation/concerns Extremities/hips Avoid risky or violent situations Dental Oral Health Risk Assessment Healthy dating relationships Neurological Developmental Surveillance Feeling sad/angry/fearful Handling depression/suicide Social-Emotional Communicative Normal Growth and Development Family Support and Relationships Cognitive Physical Development Tanner Stage Substance Abuse, Child Abuse, Domestic Screening for Abuse Y N Psychosocial/Behavioral Assessment Violence Prevention, Depression If Risk: Y N Know who your teen spends time with IPPD (result) Alcohol & Drug Use (risk assessment) Spend family time together Hct or Hgb (result) Y N Home, school, community rules Dyslipidemia (result) (to be done Abnormal Findings and Comments once between 18 and 20 years old) Respect others STI Screening (result) Discuss future plans/College/Career Cervical Dysplasia (result) (see additional note area on next page) School frustrations/dropping out Sickle Cell (if not previously tested) Results of visit discussed with child/parent Encourage to volunteer/participate with (result) Y N religious, school or community activities Immunizations: Plan Next Well Check years of age Immunizations Reviewed, Given & Charted History/Problem List/Meds Updated Developmental Questions and Observations (according to AAP.org guidelines) Referrals on Page 2 If needed but not given, document rationale Children Special Health Care Needs Provider Signature Impactsis (OH registry) updated Dental Transportation Other

WELL CHILD EXAM - ADOLESCENCE: 15 - 20 YEARS

Date Patient Name DOB

Developmental Questions and Observations You may use the following screening list, or an age appropriate standardized developmental instrument or screening tool.

Ask the patient to respond to the following statements: Yes No Please tell me any questions or concerns you have today:

I eat breakfast everyday. I am happy with how I am doing in school and/or at work. I have one or more close friends. I feel rested when I wake up. I participate in at least one activity and/or interest other than school and work. I do things with my family. I feel good about my friends and school. I know what to do when I feel angry, stressed or frustrated. I have someone I can talk to. I have questions about sexuality. I get some physical activity every day. I sometimes feel really down and depressed. I sometimes feel very nervous.

If the parent is present, ask the parent to respond to the following statements: Yes No I am proud of my child. I talk to my child about alcohol, drugs, and smoking. My child‘s school work matches his/her future goals. My child‘s school work matches my future goals for him/her. I talk to my child about sexuality and our family’s values regarding sex. I monitor my child’s activities and social life.

Additional Notes from pages 1 and 2:

Staff Signature Provider Signature

My Health at 15 - 20 Years Health Tips Milestones Talk with your doctor at each visit about your health and learn what Your development between 15 and 20 years of age. to do when you have a cold, an earache, or the flu. You should • You will keep making more decisions for yourself, plan for your have regular health, vision and dental check-ups. life after high school, and discover new skills and talents. You need at least 8 hours of sleep each night to do your best at • This can be an exciting time for you but also can be very school, work or when driving. emotional. This is part of the growing process. You can learn to

manage stress or anger by taking a class with a friend or your A healthy diet is important. You need certain foods to help you parents. grow during your teen years. If you are worried about your weight, • Teens face many tough choices and may feel more pressures to check with your doctor. Diet for weight loss should be done only make the wrong choice. This is an important time to talk to with a doctor or nurse’s help. Exercise, healthy foods and fewer friends, parents, family members and trusted teachers to help snacks are the best way to lose weight. Make a goal to be you learn to make the right choices. physically active at least 60 minutes each day. It doesn’t have to be all at once. Find activities that you enjoy. For Help or More Information: Firearm safety: Learn about sexuality, abstinence, sexually transmitted infections Call 1-202-662-0600 or go to www.safekids.org and birth control. Be sure you know how and why to say “NO” to sex. Talk to your parents, doctor, nurse or adult advisor about Crisis Intervention/Suicide Prevention Information: making sexual decisions. • The National Crisis 24/7 Helpline at 1-800-999-9999 or visit www.nineline.org Everyone feels depressed sometimes. It can be serious so see • Girls & Boys Town 24/7 Suicide and Crisis Line: 800-448-3000 your doctor or find a counselor if you, or someone you know has or visit www.girlsandboystown.org/hotline several of the following signs for more than two weeks: • Depressed/irritable mood most of the day, nearly every day Social Support Services: • Loss of interest or pleasure in usual activities Contact the local county Department of Job and Family Services • Noticeable change in appetite or weight (when not dieting or Healthchek Coordinator trying to gain weight) • Trouble sleeping or sleeping too much Sexuality Information for teens: • ® Speaking and/or moving with unusual speed or slowness (Planned Parenthood Federation of America) www.teenwire.com • Fatigue or loss of energy nearly every day Gambling: • Feelings of worthlessness or excessive guilt • Gamblers Anonymous Michigan Hotline Number: (888) 844- • Decreased ability to think or concentrate, or unable to make 2891 or online at www.gamblersanonymous.org decisions, nearly every day • Thoughts of death, suicide, wishes to be dead or suicide AIDS Hotlines: attempts • AIDS.GOV website online at www.aids.gov • Abusing drugs, alcohol or other substances • National AIDS Hotline: 1-800-CDC-INFO (1-800-232-4636) or online at www.cdc.gov Safety Tips • 24-Hour Hotline (Public Health Service): 1-800-342-2437 Use safety equipment, helmets, pads and seat belts.

Eating Disorders: Driving is most risky for teenagers when they have other teens in Call the Eating Disorder Hotline 1-800-931-2237 or visit the car. You and your parents should agree on clear rules about www.nationaleatingdisorders.org driving, especially with your friends.

Domestic Violence hotline: Never drive drunk or ride with anyone who has been drinking. Remember, “Friends don’t let friends drive drunk.” They also don’t • National Domestic Violence Hotline - (800) 799-SAFE (7233) or let friends ride with a drunk. online at www.ndvh.org • Rape, Abuse, and Incest National Network at 1-800-656-HOPE Learn gun safety. Never play around with guns. If there are guns (4673) or rifles in your home, make sure they are unloaded and locked up. • State of Ohio Child Protection: 866-635-3748

Information for teens and their parents: Provides information for teens and parents of teen on many teen topics. http://www.kidshealth.org/