Form DHCS 4496 American Indian Infant Health Initiative (Aiihi) Database Form - California

Form DHCS4496 or the "American Indian Infant Health Initiative (aiihi) Database Form" is a form issued by the California Department of Health Care Services.

Download a fillable PDF version of the Form DHCS4496 down below or find it on the California Department of Health Care Services Forms website.

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State of California–Health and Human Services Agency
Department of Health Care Services
AMERICAN INDIAN INFANT HEALTH INITIATIVE (AIIHI)
DATABASE FORM
FSW/CHR complete within first quarter of service and submit with an initial Quarterly Progress Report (DHCS 4496).
Clinic name
Enrollment date (mm/dd/yy)
[ Clinic Name ]
Client/Mother (MOB) Data
MOB ID number
MOB date of birth
Age
0
American Indian
Education–highest grade completed
Still in school
Ye s
No
Ye s
No
Marital status
Gravida (including the current pregnancy) Para
Single
Married
Divorced
Separated
Currently pregnant
EDC (mm/dd/yy)
Date of first prenatal visit (mm/dd/yy) Trimester:
Ye s
No
If yes, complete the following:
First
Second
Third
Recently gave birth
Date of birth
Birth weight child #1
Birth weight child #2
32423
3434
23423
3423
12/03/00
Ye s
No
If yes, complete the following:
_______ lbs. _______ oz.
_______ oz.
______ lbs.
Type of birth
Gestation
Singleton
Multiple
Preterm (-37 weeks)
Full term (38-42 weeks)
Post term (43+ weeks)
Birth Complications (Check all that apply.)
Mother
Child #1
Child #2
None
None
None
Medical (including C-section)
Medical
Medical
Drug/alcohol use-related
Drug/alcohol exposure
Drug/alcohol exposure
Infections
Developmental
Developmental
Other (explain): ________________________________
Other (explain): __________________
Other (explain): __________________
Living with (check all that apply):
Number in household
Friend(s)
Alone
Father of baby (FOB)
Parent(s)/extended family
Other (explain):___________________________________________
Spouse/Partner (other than FOB)
Source of income (check all that apply):
Employment
TANF
Father of baby (FOB)
Parent(s)/extended family
Other (explain):___________________________________________
How old?
Has child(ren) under age 5 (NOT including the newborn described above)
How many?
Ye s
No
If yes, complete the following:
Father (FOB) Data
American Indian
Date of birth (mm/dd/yy) Age
If DOB is unknown, enter estimated age Involved with pregnancy/child
Ye s
No
Unknown
Ye s
No
Unknown
Assessments (Maternal/Child Risk Profile)
Not done (If checked, submit the results in following quarter.)
Client/MOB Psychosocial Risk Factors (Check all reported and/or observed risks.)
None identified
* 1. Substance abuse or positive toxicity:
wi th
OR
without treatment (explain):
______________________________
* 2. Maternal Hx of mental illness or developmental delay (parent)
* 3. Maternal Hx of child abuse, rape, molestation, or incest (as a victim)
* 4. Age <18 years or >40 years
5. Single, separated (legal or geographical), divorced
6. Self or partner unemployed or seasonal employment
th
7. Education <12
grade or illiterate (English or other language)
8. Inadequate income (<200% FPL or on Medi-Cal)
9. Unstable housing (homeless, frequent moves, overcrowded, multifamily)
10. No telephone or message only
11. Lack of transportation/public transport or dependent on others
12. First-time mother
13. Late (after third trimester), inadequate/sporadic, or no prenatal care
14. Hx of therapeutic abortion (actual or contemplated) or multiple miscarriages
15. Depression or suicidal ideation (past or present)
16. Child(ren) in foster home placement (past or present) or CPS involvement
17. Hx of domestic/family violence or rape/sexual assault (as a victim)
18. Other (e.g., no support system/person, unplanned pregnancy, unrealistic expectation of child development)
(explain):
ffsdfsdfsd
Score
*
s
is wo
Each of factor
1-4
rth 10 points each.
Each of factors 5œ18 is worth 1 point.
0
t
A
s
) scores 5-9 with significant medical risk(s) (see —Medical Risk Factors" on the following page.
Refer clien
to
IIHI if she: (1) score
10 or higher; or (2
Page 1 of 2
DHCS 4495 (5/07)
State of California–Health and Human Services Agency
Department of Health Care Services
AMERICAN INDIAN INFANT HEALTH INITIATIVE (AIIHI)
DATABASE FORM
FSW/CHR complete within first quarter of service and submit with an initial Quarterly Progress Report (DHCS 4496).
Clinic name
Enrollment date (mm/dd/yy)
[ Clinic Name ]
Client/Mother (MOB) Data
MOB ID number
MOB date of birth
Age
0
American Indian
Education–highest grade completed
Still in school
Ye s
No
Ye s
No
Marital status
Gravida (including the current pregnancy) Para
Single
Married
Divorced
Separated
Currently pregnant
EDC (mm/dd/yy)
Date of first prenatal visit (mm/dd/yy) Trimester:
Ye s
No
If yes, complete the following:
First
Second
Third
Recently gave birth
Date of birth
Birth weight child #1
Birth weight child #2
32423
3434
23423
3423
12/03/00
Ye s
No
If yes, complete the following:
_______ lbs. _______ oz.
_______ oz.
______ lbs.
Type of birth
Gestation
Singleton
Multiple
Preterm (-37 weeks)
Full term (38-42 weeks)
Post term (43+ weeks)
Birth Complications (Check all that apply.)
Mother
Child #1
Child #2
None
None
None
Medical (including C-section)
Medical
Medical
Drug/alcohol use-related
Drug/alcohol exposure
Drug/alcohol exposure
Infections
Developmental
Developmental
Other (explain): ________________________________
Other (explain): __________________
Other (explain): __________________
Living with (check all that apply):
Number in household
Friend(s)
Alone
Father of baby (FOB)
Parent(s)/extended family
Other (explain):___________________________________________
Spouse/Partner (other than FOB)
Source of income (check all that apply):
Employment
TANF
Father of baby (FOB)
Parent(s)/extended family
Other (explain):___________________________________________
How old?
Has child(ren) under age 5 (NOT including the newborn described above)
How many?
Ye s
No
If yes, complete the following:
Father (FOB) Data
American Indian
Date of birth (mm/dd/yy) Age
If DOB is unknown, enter estimated age Involved with pregnancy/child
Ye s
No
Unknown
Ye s
No
Unknown
Assessments (Maternal/Child Risk Profile)
Not done (If checked, submit the results in following quarter.)
Client/MOB Psychosocial Risk Factors (Check all reported and/or observed risks.)
None identified
* 1. Substance abuse or positive toxicity:
wi th
OR
without treatment (explain):
______________________________
* 2. Maternal Hx of mental illness or developmental delay (parent)
* 3. Maternal Hx of child abuse, rape, molestation, or incest (as a victim)
* 4. Age <18 years or >40 years
5. Single, separated (legal or geographical), divorced
6. Self or partner unemployed or seasonal employment
th
7. Education <12
grade or illiterate (English or other language)
8. Inadequate income (<200% FPL or on Medi-Cal)
9. Unstable housing (homeless, frequent moves, overcrowded, multifamily)
10. No telephone or message only
11. Lack of transportation/public transport or dependent on others
12. First-time mother
13. Late (after third trimester), inadequate/sporadic, or no prenatal care
14. Hx of therapeutic abortion (actual or contemplated) or multiple miscarriages
15. Depression or suicidal ideation (past or present)
16. Child(ren) in foster home placement (past or present) or CPS involvement
17. Hx of domestic/family violence or rape/sexual assault (as a victim)
18. Other (e.g., no support system/person, unplanned pregnancy, unrealistic expectation of child development)
(explain):
ffsdfsdfsd
Score
*
s
is wo
Each of factor
1-4
rth 10 points each.
Each of factors 5œ18 is worth 1 point.
0
t
A
s
) scores 5-9 with significant medical risk(s) (see —Medical Risk Factors" on the following page.
Refer clien
to
IIHI if she: (1) score
10 or higher; or (2
Page 1 of 2
DHCS 4495 (5/07)
Assessments (Maternal/Child Risk Profile) (continued)
Medical Risk Factors (This section to be completed by PHN.)
Client/MOB
No risk factors
Hx of birth of preterm (<38 weeks), LBW (<2,500g), or SGA infant (explain):
Chronic medical conditions or complications (explain):
Significant communicable disease and/or tuberculosis (explain):
Previous infant mortality (explain):
Other (e.g., gestational diabetes) (explain):
Infant (0œ1 year)
Infant in home?
Yes
(DOB [mm/dd/yy: _______________])
No
If yes, complete the following:
No risk factors
Failure to thrive (explain):
Premature (<38 weeks), LBW (<2,500g), or SGA (explain):
Acute or chronic major medical condition (explain):
Known or at risk for developmental delay (explain):
Abused, neglected, or not safe (explain):
Significant communicable disease and/or tuberculosis (explain):
Fetal exposure to drug(s) (explain):
Other (explain):
Toddler (1œ2 years)
Toddler in home?
Yes
(DOB [mm/dd/yy: _______________])
No
If yes, complete the following:
No risk factors
Acute or chronic major medical condition (explain):
Abused, neglected, or not safe (current) (explain):
Significant communicable disease and/or tuberculosis (explain):
Other (explain):
Preschooler (3œ4 years)
Preschooler in home?
Yes
(DOB [mm/dd/yy: _______________])
No
If yes, complete the following:
No risk factors
Acute or chronic major medical condition (explain):
Abused, neglected, or not safe (current) (explain):
Significant communicable disease and/or tuberculosis (explain):
Other (explain):
Completed by
Date last updated
Page 2 of 2
DHCS 4495 (5/07)

Download Form DHCS 4496 American Indian Infant Health Initiative (Aiihi) Database Form - California

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