When this form is completely - Mississippi Medicaid
When this form is completely
Filled out use EPSDT Screening Code:
99381 – New Patient < one year
99391-Established Patient < one year
|1 |M |EPSDT Screening | | |/ | | |/ |2 |0 | | |Medicaid ID# | | | | | | | | | | |
One Month Visit
Name_____________________________________Birthdate_______________Historian_____________________
Age_________Allergies_________________Medications______________________________________________
*Weight______lbs. _______oz. *Length ________in. *Head circ. _________cm Temp. ______P_____ R____
*Plot on growth chart
Nutrition
□ Breast _______min. q._______hrs.
□ Formula _______ oz. q. ______hrs.
Brand _______________________
With iron? Yes No
WIC: yes no
Initial History (Prenatal, Birth and
Family Documentations)
History Update
Are there any changes in your family history?
No Yes_______________________
Has the patient had any new problems or
illnesses since the last visit?
No Yes _______________________
Problems/Concerns
Spitting up yes no
Constipation yes no
Colic yes no
Safety Impression
Stuffy nose yes no □ Car seat, facing backwards □ Well baby
Sleep yes no □ Smoke free environment □ __________________
____________________________________ □ Smoke detectors in home □ __________________
____________________________________ □ Hot water < 120 degrees □ __________________
____________________________________ □ No bottle propping □ __________________
□ Sleep on back
Hearing □ Crib Safety Plan/Referrals
Responds to sounds yes no Health/Nutrition Immunization Record
Newborn hearing screen: □ If bottle fed, 26-32oz/day Immunization up to date
Normal Repeat Not done □ If breast fed, nurses 8-10 times/day Yes _____ No________
Vision: □ Delay solids Vaccine Information Sheet
Look at parent’s face yes no □ Bowel movements One month Handout sheet
Follows with eyes yes no □ Strong urinary stream, if male RTC at 2 months
□ Fever ____________________________
Developmental Screen: Social/Behavioral __________________________
See separate form □ Temperament
Normal abnormal □ Sleep ___________________________M.D./N.P
□ Talk to baby Print Name
□ Support for mother ____________________________________
□ Day care plans yes no Signature
-----------------------
Physical Exam (UNCLOTHED Yes No) √ = nl X = abnl
General □
Head □
Fontanel □
Neck □
Eyes □
Red Reflex □
Ears □
Nose □
Throat □
Lungs □
Heart □
Abdomen □
Femoral Pulses □
Umbilical Cord □
Genitalia
Female □
Male □
Testes □
Circumcision □
Spine □
Extremities □
Hips □
Skin □
Neuro □
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