ࡱ>   y B^bjbj .{{ Gc;  z%z%z%z%z%D%%%oKl%W>&N 3(3334L466`HS*V*V*V*V*V*V$Yo\xNVAz%P744P7P7NVz%z%334W===P7z%3z%3HS=P7HS==KtM3[8Ms7rL"4SW0WL]b9]DtM]z%MP7P7=P7P7P7P7P7NVNV|;>P7P7P7WP7P7P7P7]P7P7P7P7P7P7P7P7P7  @$: WELL CHILD EXAM MIDDLE CHILDHOOD: 6-10 YEARSAuthority: P.A. 116 of 1973 Completion: Required Consequences of non-completion: Non-compliance of licensing rules.Michigan Department of Human ServicesWell Child Exam Date FORMTEXT      PATIENT NAMEDOBSEXPARENT NAME FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      AllergiesCurrent Medications FORMTEXT       FORMTEXT      Prenatal/Family History FORMTEXT      WeightPercentileLengthPercentileBMIPercentileTemp.PulseResp.BP FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Interval History: (Include injury/illness, visits to other health care providers, changes in family or home) FORMTEXT      Nutrition FORMCHECKBOX Grains FORMTEXT      servings per day FORMCHECKBOX Fruit/Vegetables FORMTEXT      servings per day FORMCHECKBOX Whole Milk FORMTEXT      servings per day FORMCHECKBOX Meats/Beans FORMTEXT      servings per day FORMCHECKBOX City water FORMCHECKBOX Well water FORMCHECKBOX Bottle WaterElimination FORMCHECKBOX Normal FORMCHECKBOX AbnormalExercise AssessmentPhysical Activity: FORMTEXT      Minutes per daySleep FORMCHECKBOX Normal FORMCHECKBOX AbnormalAdditional area for comments on page 2Screening and Procedures: FORMCHECKBOX Oral Health Risk Assessment (6 year olds)Hearing FORMCHECKBOX Screening audiometry (6 Years olds; 7-10 year olds if risk assessment positive FORMCHECKBOX Parental observation/concernsVision FORMCHECKBOX Visual acuity FORMTEXT   R FORMTEXT   L FORMTEXT   Both FORMCHECKBOX Parental observation/concernsDevelopmental Screening FORMCHECKBOX Social Emotional FORMCHECKBOX Communicative FORMCHECKBOX Cognitive FORMCHECKBOX Physical DevelopmentPsychosocial/Behavioral Assessment FORMCHECKBOX Yes FORMCHECKBOX NoScreening for Abuse FORMCHECKBOX Yes FORMCHECKBOX NoScreen If Risk: FORMCHECKBOX IPPD FORMTEXT      (result) FORMCHECKBOX Hct or Hgb FORMTEXT      (result) FORMCHECKBOX Dyslipidemia FORMTEXT      (result) at 6, 8 10 yrs.If not previously tested: FORMCHECKBOX Lead level FORMTEXT      mcg/dl (for 6 year olds-Required for Medicaid)Immunizations: FORMCHECKBOX Immunizations Reviewed, Given & Charted if needed but not given, document rationale FORMCHECKBOX DTaP FORMCHECKBOX IPV FORMCHECKBOX MMR FORMCHECKBOX Influenza FORMCHECKBOX Varicella or Chicken Pox Date: FORMTEXT       FORMCHECKBOX MCIR checked/updated FORMCHECKBOX Acetaminophen FORMTEXT      Mg. q. 4 hoursPatient Unclothed FORMCHECKBOX Yes FORMCHECKBOX NoReview of SystemsPhysical ExamSystemsNANA FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX General Appearance FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Skin/nodes FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Head FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Eyes FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Ears FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Nose FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Oropharynx FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Gums/palate FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Neck FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Lungs FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Heart/pulses FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Abdomen FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Genitalia FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Spine FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Extremities/hips FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Neurological  FORMCHECKBOX Normal Growth and Development FORMCHECKBOX Tanner Stage FORMCHECKBOX Abnormal Findings and CommentsIf yes, see additional note area on next pageResults of visit discussed with child/parent FORMCHECKBOX Yes FORMCHECKBOX NoPlan FORMCHECKBOX History/Problem List/Meds Updated FORMCHECKBOX Referrals FORMCHECKBOX Children Special Health Care Needs FORMCHECKBOX Transportation FORMCHECKBOX Other FORMTEXT       FORMCHECKBOX Other FORMTEXT      Anticipatory Guidance/Health Education(check if discussed)Safety FORMCHECKBOX Discuss avoiding alcohol, tobacco, drugs FORMCHECKBOX Monitor TV viewing & computer games FORMCHECKBOX Booster seat/seat belt use in backs seat FORMCHECKBOX Keep home and care smoke-free FORMCHECKBOX Teach outdoor, bike, and water safety FORMCHECKBOX Use bike helmet/protective sporting gear FORMCHECKBOX Teach stranger and home safety FORMCHECKBOX Gun safetyNutrition/physical activity FORMCHECKBOX Limit sugar and high fat food/drinks FORMCHECKBOX Regular family meals. FORMCHECKBOX Offer variety of healthy foods and include 5 servings of fruits &veggies every day FORMCHECKBOX Limit TV, video, and computer games FORMCHECKBOX Physical activity & adequate sleepOral Health FORMCHECKBOX Schedule dental appointment FORMCHECKBOX Discuss flossing, fluoride, sealantsChild Development and Behavior FORMCHECKBOX Encourage independence FORMCHECKBOX Answer questions about puberty simply FORMCHECKBOX Consistently reinforce limits & family rules FORMCHECKBOX Praise child and encourage child to talk about feelings, school, and friends FORMCHECKBOX Supervise childs activities FORMCHECKBOX Assign household tasks & responsibilitiesFamily Support and Relationships FORMCHECKBOX Listen/show interest in childs activities FORMCHECKBOX Spend family time together FORMCHECKBOX Set reasonable but challenging goals FORMCHECKBOX Encourage positive interaction with siblings, teachers and friends FORMCHECKBOX Offer constructive ways to handle family conflict and anger; dont allow violence FORMCHECKBOX Know childs friends and their families FORMCHECKBOX Be a positive role model for your child FORMCHECKBOX Substance Abuse, Child Abuse, Domestic Violence Prevention, Depression FORMCHECKBOX Ensure safe, supervised after school careNext Well Check: FORMTEXT   years of ageDevelopmental Surveillance on Page 2 Page 3 required for Foster Care ChildrenMedical Provider Signature: PAGE 2  WELL CHILD EXAM  MIDDLE CHILDHOOD: 6  10 Year  Developmental Surveillance (This page may be used if not utilizing a Validated Developmental Screener)DateChild s NameDOB FORMTEXT       FORMTEXT       FORMTEXT      Developmental Questions and ObservationsAsk the parent to respond to the following statements about the child:YesNo FORMCHECKBOX  FORMCHECKBOX Please tell me any concerns about the way your child is behaving or developing FORMTEXT       FORMCHECKBOX  FORMCHECKBOX My child has hobbies or interests that he/she enjoys. FORMCHECKBOX  FORMCHECKBOX My child follows rules in home, school and the community, most of the time. FORMCHECKBOX  FORMCHECKBOX My childs behavior, relationships and school performance are appropriate most of the time. FORMCHECKBOX  FORMCHECKBOX My child handles stress, anger, frustration well, most of the time. FORMCHECKBOX  FORMCHECKBOX My child eats breakfast every day. FORMCHECKBOX  FORMCHECKBOX My child is doing well in school. FORMCHECKBOX  FORMCHECKBOX My child talks to me about school, friends and feelings. FORMCHECKBOX  FORMCHECKBOX My child seems rested when he/she wakes up. FORMCHECKBOX  FORMCHECKBOX My child gets some physical activity every day.Ask the parent to respond to the following statements:YesNo FORMCHECKBOX  FORMCHECKBOX I know what to do when I am frustrated with my child. FORMCHECKBOX  FORMCHECKBOX I enjoy seeing my child become more independent and self-reliant. FORMCHECKBOX  FORMCHECKBOX Our family has experienced major stresses and/or changes since our last visit. FORMCHECKBOX  FORMCHECKBOX It is hard 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:YesNo FORMCHECKBOX  FORMCHECKBOX I feel good about my friends and school. FORMCHECKBOX  FORMCHECKBOX I know what to do when another child or adult tries to bully me or hurt me.Provider to follow up as necessary.Developmental MilestonesAlways ask parents if they have concerns about development or behavior. (You may use the following screening list, or a standardized developmental instrument or screening tool).Child DevelopmentStates phone number and home addressYesNoReading and math are at grade levelYesNoHas close friend(s)YesNoChild communicates/expresses selfYesNoChild responds to parent and health care providerYesNoPlease note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing observation is not anticipated. (Bright Futures: Guidelines for health supervision of Infants, Children, and Adolescents)Additional Notes from pages 1 and 2 FORMTEXT      Medical Staff SignatureMedical Provider Signature THIS PAGE IS REQUIRED FOR FOSTER CARE CHILDREN PAGE 3  WELL CHILD EXAM  MIDDLE CHILDHOOD: 6  10 YearsDateChild s NameDOB FORMTEXT       FORMTEXT       FORMTEXT      Name of person who accompanied child to appointment FORMCHECKBOX Parent FORMTEXT       FORMCHECKBOX Foster ParentPhone number of person who accompanied child to appointment FORMCHECKBOX Relative Caregiver (specify relationship) FORMTEXT       FORMTEXT       FORMCHECKBOX Caseworker A physical exam, including developmental, psychosocial, and behavioral health screening, must be completed utilizing all Early and Periodic Screening. Diagnostic, and Treatment (EPSDT) requirements. Please attach the completed physical form utilized at this visit.Developmental, Psychosocial, and Behavioral Health Screenings (must use validated tool)Always ask child, parents and/or guardian if they have concerns about development or behavior. 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Plans, and Michigan Association of Local Public Health.Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. Provide child s caregiver/foster parent with handout.PARENT/CAREGIVER HANDOUT Your Child s Health at 6-10 Years Milestones Ways your child is developing between 6 and 10 years. Your child should continue to loose baby teeth and get permanent teeth Some girls breasts will begin to grow between 8 and 10 years of 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 themselves You help your child learn new skills by talking and playing with them. Make a game of practicing hand signals or saying  No when a stranger offers them a ride. Your child will keep growing more independent For Help or More Information: Child sexual abuse, physical abuse, information and support: Contact the Child Abuse and Neglect Information Hotline or Parents HELPline at 1-800-942-4357 The Michigan Coalition Against Domestic & Sexual Violence at 1-517-347-7000 or online at HYPERLINK "C:\\Documents and Settings\\bushd2\\Desktop\\www.mcadsv.org"www.mcadsv.org Childhelp National Child Abuse Hotline 1-800-4-A-CHILD (1-800-422-4453) or online at HYPERLINK "C:\\Documents and Settings\\bushd2\\Desktop\\www.childhelp.org"www.childhelp.org Age Specific Safety Information: Call 1-202-662-0600 or go to  HYPERLINK "http://www.safekids.org/safety-basics/" http://www.safekids.org/safety-basics/ Domestic Violence hotline: National Domestic Violence Hotline  (800) 799-SAFE (7233) or online at HYPERLINK "C:\\Documents and Settings\\bushd2\\Desktop\\www.ndvh.org"www.ndvh.org Parenting skills or support: Call the Parents Hotline at 1-800-942-4357 or the Family Support Network of Michigan at 1-800-359-3722. For help teaching your child about fire safety: Talk with firefighters at your local fire station Children s Mental Health parent support and advocacy: Contact the Association of Children s Mental Health (ACMH) at 1-888-ACMH-KID (226-4543) or online at HYPERLINK "C:\\Documents and Settings\\bushd2\\Desktop\\www.acmh-mi.org"www.acmh-mi.org Health Tips: Your child will still need you to help get all of their teeth brushed well. Make sure to take your child for a dental check-up at least once a year. Ask about dental sealants. You and your child should be physically active at least 60 minutes each day. It doesn t have to be all at once. Find activities that you and your child enjoy. This is an important habit for your child to learn. Keep healthy snacks available. Your child needs fruit, vegetables, juice, and whole grains for growth and energy.Parenting Tips: Praise your child when he works hard and finishes things. Most children learn by watching and then doing. Show and tell 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 differently. Talk about why children should not use drugs and alcohol. Set a good example for your child Teach your child what to do and not do when they re angry. Make sure your computer is in a room where you can watch your child s use of the internet. Set limits and tell your child what will happen if he doesn t follow rules. Teach your child how to deal with peer pressure. Encourage your child to join community groups, team sports, school clubs and other activities. If you feel very mad or frustrated with your child: Make sure your child is in a safe place and walk away. Call a friend to talk about what you are feeling. Call the free Parent Helpline at 1-800-942-4357 (in Michigan). They will not ask your name and can offer helpful support and guidance. The helpline is open 24 hours a day. Calling does not make you weak; it makes you a good parent. Safety Tips Make sure that everyone who rides in the car with you wears their seat belt. Help you child know to ask to use a seat belt or booster when he rides with other drivers. Practice family safety in your house; test the smoke alarm and change the batteries when needed; have fire drills and practice fire escape plan. Your child should always wear a lifejacket around water, even after she has learned to swim. Make sure your child wears a helmet when using bikes, skates, inline skates, scooters, and skateboards. Practice safe walking and bike riding. Children are not ready to ride bikes safely on streets or cross streets without an adult until they reach at least age 9. 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 home are unloaded and locked up.Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.*Handout from Institute for Health Care Studies at Michigan State University.     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