DCS 125 CPS (7/04) - Foster Parent Forms - Foster Parent Forms
SAN BERNARDINO COUNTY CHILDREN and FAMILY SERVICESREPORT OF MEDICAL / DENTAL EXAMFOR HEALTH PASSPORT UPDATEFAX or RETURN in the POSTPAID ENVELOPE FFA must give original to social worker or PHN PUBLIC HEALTH NURSE CHILD: ______________________________________CWS # ______________________________________DOB: ______________________________________WORKER NAME:______________________________ TO BE COMPLETED BY THE MEDICAL / DENTAL PROVIDER: ICD-9 (IF EASILY AVAILABLE)DX:________________________________________________________________________RX:________________________________________________________________________Immunizations Given Today: (Please Check) FORMCHECKBOX DtaP #1 FORMCHECKBOX IPV #1 FORMCHECKBOX Hib #1 FORMCHECKBOX Rota #1Results of tests done today FORMCHECKBOX DtaP #2 FORMCHECKBOX IPV #2 FORMCHECKBOX Hib #2 FORMCHECKBOX Rota #2 FORMCHECKBOX DtaP #3 FORMCHECKBOX IPV #3 FORMCHECKBOX Hib #3 FORMCHECKBOX Rota #3HEIGHT HEARING FORMCHECKBOX DtaP #4 FORMCHECKBOX IPV #4 FORMCHECKBOX Hib #4Head circ<2yr______ FORMCHECKBOX DtaP #5 FORMCHECKBOX MCVWEIGHT VISION FORMCHECKBOX Td/Tdap #6 FORMCHECKBOX MMR #1 FORMCHECKBOX Varcella #1 FORMCHECKBOX BMI _________ FORMCHECKBOX MMR #2 FORMCHECKBOX Varcella #2 FORMCHECKBOX HPV #1 FORMCHECKBOX BP / _ FORMCHECKBOX HPV #2 FORMCHECKBOX TB TEST RESULTS FORMCHECKBOX Hep B #1 FORMCHECKBOX PCV #1 FORMCHECKBOX HEP A #1 FORMCHECKBOX HPV #3 FORMCHECKBOX Hep B #2 FORMCHECKBOX PCV #2 FORMCHECKBOX HEP A #2 FORMCHECKBOX HGB FORMCHECKBOX Hep B #3 FORMCHECKBOX PCV #3 FORMCHECKBOX Influenza FORMCHECKBOX LEAD SCREENING: FORMCHECKBOX PCV #4 OTHER TEST: Other Immunizations: TYPE OF VISIT: Medical Dental Vision Follow up Purpose: Routine Comprehensive (Well Child) Specialist visit Tx Completed Medication prescribed Sick visit Tx OngoingWAS CHILD REFERRED TO ANOTHER PROVIDER? NO YES (If Yes, please complete)Name: Address: Specialty: To be seen by what date: Telephone: ( ) Date of Service: Print Provider Name - Please Add Stamp:Address:City/State: Phone: ( ) PROVIDER STAMP HERE TDD – Telephone Services For The Hearing Impaired (909) 386-9780Child and Adult Abuse Hotline 1 (800) 827-8724Distribution: Original - Case RecordCopy - Caretaker ................
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