Well Child Exam Form - Infancy: 2 Months Page 3
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4THIS PAGE IS REQUIRED FOR FOSTER CARE CHILDREN
Page 3 - WELL CHILD EXAM-INFANCY: 2 Months
DATE
CHILD’S NAME
DOB
Name and phone number of person who accompanied child to appointment:
□ Parent □ Foster Parent
□ Relative Caregiver (specify
Name:
relationship)______________________
□ Caseworker
Phone Number:
Physical completed utilizing all Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements
□
Yes Please attach completed physical form utilized at this visit
□
No
If no, please state reason physical exam was not completed______________________________
________________________________________________________________________________________
Developmental, Social/Emotional and Behavioral Health Screenings
Always ask parents or guardian if they have concerns about development or behavior. (You must use a standardized developmental
instrument or screening tool as required by the Michigan Department of Community Health and Michigan Department of Human
Services).
Validated Standardized Developmental Screening and Autism Screening completed: Date_______________
Screener Used: □ ASQ □ PEDS □ PEDSDM □ Other tool:__________________ Score: __________
Referral Needed: □ No □ Yes
Referral Made: □ No
□ Yes Date of Referral:____________ Agency: _________________________________
Current or Past Mental Health Services Received: □ No □ Yes (if yes please provide name of provider)
Name of Mental Health Provider:_____________________________________________________
EPSDT Abnormal results:
Special Needs for Child (e.g., DME, therapy, special diet, school accommodations, activity restrictions, etc):
Provider Signature: ____________________________________________
Provider Name_________________________________________________
Please print
This HME form was developed by the Institute for Health Care Studies at Michigan State University in collaboration with the Michigan Medicaid managed care plans, Michigan
Department of Community Health, Michigan Department of Human Services, Michigan Association of Health Plans, and Michigan Association of Local Public Health.
Updated – 4/2011
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