Form MO886-3986 "Healthy Children and Youth Screening Guide - 16-17 Years" - Missouri

What Is Form MO886-3986?

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 November 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 MO886-3986 by clicking the link below or browse more documents and templates provided by the Missouri Department of Social Services.

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MISSOURI DEPARTMENT OF SOCIAL SERVICES
MO HEALTHNET DIVISION
HEALTHY CHILDREN AND YOUTH SCREENING GUIDE
16-17 YEARS
DATE
NAME
DATE OF BIRTH
MO HEALTHNET NUMBER
MEDICAL RECORD NUMBER
TEMP
RR
HEIGHT
BMI
ALLERGIES
%
NKDA
PULSE
BP
WEIGHT
MEDICATIONS
%
NONE
I. INTERVAL HISTORY/PARENT’S CONCERNS/CHILD’S CONCERNS:
COMMENTS
Menstrual/Reproductive Hx: Menarche age __________ years LMP: ______________
Gravida:
Para: Term
Preterm
Abortions
Living Children
Chronic Illnesses:
ER/Hospital utilization since last visit
Triggers reviewed:
Medications changed/refilled:
Education
Consult/Referral
Sleep/Fatigue:*
School:*
Peers:*
Work:*
Family High Risk Factors:*
Self Injury:*
High Risk Behaviors:*
None
Cigarettes
Alcohol
Illicit Drugs
Weapons
Sexual activity
Accidents
Other
Nutrition:
Encourage all food groups:
Output: Urine: _______________________ Stools: ____________________________
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 886-3986 (11-07)
MISSOURI DEPARTMENT OF SOCIAL SERVICES
MO HEALTHNET DIVISION
HEALTHY CHILDREN AND YOUTH SCREENING GUIDE
16-17 YEARS
DATE
NAME
DATE OF BIRTH
MO HEALTHNET NUMBER
MEDICAL RECORD NUMBER
TEMP
RR
HEIGHT
BMI
ALLERGIES
%
NKDA
PULSE
BP
WEIGHT
MEDICATIONS
%
NONE
I. INTERVAL HISTORY/PARENT’S CONCERNS/CHILD’S CONCERNS:
COMMENTS
Menstrual/Reproductive Hx: Menarche age __________ years LMP: ______________
Gravida:
Para: Term
Preterm
Abortions
Living Children
Chronic Illnesses:
ER/Hospital utilization since last visit
Triggers reviewed:
Medications changed/refilled:
Education
Consult/Referral
Sleep/Fatigue:*
School:*
Peers:*
Work:*
Family High Risk Factors:*
Self Injury:*
High Risk Behaviors:*
None
Cigarettes
Alcohol
Illicit Drugs
Weapons
Sexual activity
Accidents
Other
Nutrition:
Encourage all food groups:
Output: Urine: _______________________ Stools: ____________________________
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 886-3986 (11-07)
FULL SCREEN (I-X)
WITH REFERRAL
HEARING SCREEN
WITH REFERRAL
PARTIAL SCREEN (I-V)
WITH REFERRAL
VISION SCREEN
WITH REFERRAL
DEVELOPMENTAL AND MENTAL HEALTH SCREEN
WITH REFERRAL
DENTAL SCREEN
WITH REFERRAL
III. ANTICIPATORY GUIDANCE (Check all that apply)
COMMENTS
Peer relations*
Firearms/Homicide*
Alcohol, drugs, smoking
Hobbies
Suicide*
and driving*
Need for privacy
Vehicular accidents
Violent behavior*
School performance*
Sports injuries
Feeding:
Body image/dieting*
Bicycle safety/helmet
3 balanced meals
Discipline*
Seatbelts/Airbags
Fat content
Exercise/Physical activity
Pool/Water safety
Iron
Sex education/STD’s
Chores
Calcium
Television
Contraception/Family planning
Obesity
IV: LAB/IMMUNIZATIONS: Labs (if high risk):
Hct
UA
Lipid profile
Other: ___________________________________
If sexually active:
PAP
Rubella titer
VDRL
Chlamydia
Gonorrhea
HIV counseling
HIV testing
Immunizations given today:
UTD
Written information given
Consent signed
(Follow the recommended immunization schedule approved by the ACIP, AAP, and AAFP)
V. LEAD SCREEN N/A for this age.
VI. DEVELOPMENTAL AND MENTAL HEALTH: (Check all that apply)
COMMENTS
School/vocational performance
Stable mood
Stable sleep/appetite
Follows rules at school/accepts discipline
Stable behavior
Career planning
Follows rules at home/accepts discipline
Engages in age appropriate social activities
VII. FINE MOTOR/GROSS MOTOR: (Check all that apply)
COMMENTS
Handwriting
Sports
VIII. HEARING: This screening should be performed annually.
IX. VISION: This screening should be performed annually.
Parental perception of hearing
Parental/child’s perception of vision
Child’s perception of hearing
Observation for
blinking
tracking
Ear exam with pneumatic otoscope
pupillary response
ocular movement
Family history of hearing disorders
Objective testing including Snellen E, acuity (near and far), and
PMHx:
NICU admission/
recurrent ear infections/
color discrimination
head injury/
congenital anomalies/
meningitis/
Exam of external eye, funduscopic exam
mumps/
cerebral palsy
School performance
Tympanometry upon indication
Family history of visual disorders
Pure tone audiometry (sweep screen) upon indication
Eye injuries, foreign substances
PMHx:
NICU admission/
prolonged oxygen administration
COMMENTS
COMMENTS
X. DENTAL
Dental referral for complete diagnostic workup and
Flouride supplements if water flouridation less than 0.7 ppm (until
orthodontic evaluation, if not done
all permanent teeth have erupted.)
Teeth brushing/flossing
COMMENTS
Referral for routine preventative dental care q 6 months
Assess teeth development and oral hygiene - Teeth cleaning
ASSESSMENT/EDUCATION/PLAN
ORDERS
SIGNATURE
DATE
MO 886-3986 (11-07)
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