CHDP Required Elements

ASQ:

Communication:

Gross motor:

Fine Motor:

Problem Solving:

Personal-Social:

Interpretation / Concern / Plan:

Dental assessment performed: No problem suspected, no referral needed

Nutritional Assessment Performed: No problem suspected, no referral needed

Age appropriate anticipatory guidance was reviewed: No problem suspected

Age appropriate developmental assessment was performed: No problem suspected

Age appropriate vision and hearing assessed: No problem suspected

Age appropriate Hgb and Hct assessed: No intervention needed

Lead exposure evaluated: No problem suspected

Urinalysis: No problem suspected or Not indicated

TB risk assessed: No need for intervention

BMI Percentile: _%ile

Smoking:

- Second hand smoke exposure: Yes [_] No [_]

- The patient uses tobacco: Yes [_] No [_]

- The patient/parent was counseled about risks of tobacco use: Yes [_] No [_]

The patient is enrolled in WIC: : Yes [_] No [_]

- If yes, Ht. Wt. and Hgb and Hct checked

Vaccines: Vaccination status was evaluated. Age appropriate vaccines were recommended as follows: as above

Follow Up is recommended in _ months.