Form MO886-3994 "Healthy Children and Youth Screening Guide - 15-17 Months" - Missouri

What Is Form MO886-3994?

This is a legal form that was released by the Missouri Department of Social Services - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2007;
  • The latest edition provided by the Missouri Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MO886-3994 by clicking the link below or browse more documents and templates provided by the Missouri Department of Social Services.

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Download Form MO886-3994 "Healthy Children and Youth Screening Guide - 15-17 Months" - Missouri

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MISSOURI DEPARTMENT OF SOCIAL SERVICES
MO HEALTHNET DIVISION
HEALTHY CHILDREN AND YOUTH SCREENING GUIDE
15-17 MONTHS
DATE
NAME
DATE OF BIRTH
MO HEALTHNET NUMBER
MEDICAL RECORD NUMBER
TEMP
RR
HEIGHT
BMI
ALLERGIES
%
NKDA
PULSE
HEAD CIRC
WEIGHT
MEDICATIONS
%
%
NONE
COMMENTS
I. INTERVAL HISTORY/PARENT’S CONCERNS:
Chronic Illnesses:
ER/Hospital utilization since last visit
Triggers reviewed:
Medications changed/refilled:
Education
Consult/Referral
Naps:
Activity:
Child Care:
Crossing Eyes:
Family High Risk Factors:*
WIC Referral
Nutrition:
Milk: _____ , _____ oz/feeding _____ times per day
Nutrition:
Solid food (encourage all food groups:
Output: Urine: __________________________ Stools: _________________________
Output:
Diaper Rash: ____________________________________________________
II. UNCLOTHED PHYSICAL EXAM:
Check Growth Chart
SYSTEM
NL
ABN
NE
COMMENTS
General
Skin
Head
Eyes
Ears
Nose
Oropharynx
Neck
Lungs
Heart
Pulses
Abdomen
Back
GU
Skeletal
Neuro
SIGNATURE
DATE
MO 886-3994 (10-07)
MISSOURI DEPARTMENT OF SOCIAL SERVICES
MO HEALTHNET DIVISION
HEALTHY CHILDREN AND YOUTH SCREENING GUIDE
15-17 MONTHS
DATE
NAME
DATE OF BIRTH
MO HEALTHNET NUMBER
MEDICAL RECORD NUMBER
TEMP
RR
HEIGHT
BMI
ALLERGIES
%
NKDA
PULSE
HEAD CIRC
WEIGHT
MEDICATIONS
%
%
NONE
COMMENTS
I. INTERVAL HISTORY/PARENT’S CONCERNS:
Chronic Illnesses:
ER/Hospital utilization since last visit
Triggers reviewed:
Medications changed/refilled:
Education
Consult/Referral
Naps:
Activity:
Child Care:
Crossing Eyes:
Family High Risk Factors:*
WIC Referral
Nutrition:
Milk: _____ , _____ oz/feeding _____ times per day
Nutrition:
Solid food (encourage all food groups:
Output: Urine: __________________________ Stools: _________________________
Output:
Diaper Rash: ____________________________________________________
II. UNCLOTHED PHYSICAL EXAM:
Check Growth Chart
SYSTEM
NL
ABN
NE
COMMENTS
General
Skin
Head
Eyes
Ears
Nose
Oropharynx
Neck
Lungs
Heart
Pulses
Abdomen
Back
GU
Skeletal
Neuro
SIGNATURE
DATE
MO 886-3994 (10-07)
FULL SCREEN (I-X)
WITH REFERRAL
HEARING SCREEN
WITH REFERRAL
PARTIAL SCREEN (I-V)
WITH REFERRAL
VISION SCREEN
WITH REFERRAL
DEVELOPMENTAL & MH SCREEN
WITH REFERRAL
DENTAL SCREEN
WITH REFERRAL
III. ANTICIPATORY GUIDANCE (Check all that apply)
Speech development
COMMENTS
Temper tantrums*
Choking hazards - nuts, popcorn, hotdog
Feeding:
Rule setting
Window guards
3 meals with snacks
Simple games
Hot/Cold
Soft drink warning
Naps
Water heater temperature (<130 F)
Self feeding
Lower crib mattress
Bathtub safety
Using a cup
Matches, lighters
Toddler car seats/airbags
Variable appetite*
Knives
Poisons/medicines
Proper serving sizes
Reading to child
Smoke Detector
Sweets
Parental smoking
IV: LAB/IMMUNIZATIONS: Labs:
Blood lead level (if not done previously)
Other ______________________________________
Immunizations given today:
UTD
Written information given
Consent signed
(Follow the recommended immunization schedule approved by the ACIP, AAP, and AAFP)
V. LEAD SCREEN
Lead Assessment Guide complete
Negative screen
Positive screen - draw blood lead level
VI. DEVELOPMENTAL AND MENTAL HEALTH:
Parents As Teachers referral (Check all that apply)
Minimal Skills
Emerging Skills
COMMENTS
Plays pat-a-cake - R
Indicates wants - R
Simple commands
Listens to story
Waves bye-bye - R
Exhibits a range of
One body part
Feeds self
Combines syllables - R
emotions
3-6 words
Jabbers - R
Engages in reciptocal
Indicates wants without crying
Dada/Mama specific - R
play/imitates behavior
Drinks from cup independently (no spout)
VII. FINE MOTOR/GROSS MOTOR: (Check all that apply)
Minimal Skills
Emerging Skills
COMMENTS
Stacks 2 blocks
Kicks ball
Bangs 2 cubes in hands - R
Thumb-finger grasp
Walks backward
Climbs stairs
Stoops and recovers
Stands alone
Runs
Uses spoon
Walks well
Puts block in cup
VIII. HEARING: (Check all that apply)
IX. VISION: (Check all that apply)
Parental perception of hearing
Parental perception of vision
Awakes to loud noise
Observation for
Head turning with noise
blinking
Cover test
Ear exam with pneumatic otoscope
pupillary response
Enjoys short books, bright pictures
Observational screening with noisemaker
red reflex/fundus
ERA/ABR screen for infant in tertiary care > 5 days
tracking
Family history of hearing disorders
ocular movements
PMHx:
NICU admission/
ear infection/
head injury/
Family history of visual disorders
congenital anomalies/
meningitis/
mumps/
cerebral palsy
Attempts to pick up small objects, bits of food
Tympanometry
PMHx:
NICU admission/
prolonged oxygen administration
3-4 words other than “Mama”, “Dada”
Repeats sound
COMMENTS
COMMENTS
NOTE: It is recommended that assessment preventive dental services
X. DENTAL
Teeth brushing by parents
and oral treatments for children begin at age 6-12 months and be
Normal tooth eruption times
Teething behavior
repeated every 6 months or as medically indicated.
Assess teeth development and oral hygiene - Teeth cleaning
COMMENTS
Fluoride supplements if water fluoridation less that 0.7 ppm
ASSESSMENT/EDUCATION/PLAN
ORDERS
SIGNATURE
DATE
MO 886-3994 (10-07)
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