Birth History/Parent Concerns Physical Examination (Unclothed)
Birth History/Parent Concerns Physical Examination (Unclothed)
Birth History/Parent Concerns Physical Examination (Unclothed)
Immunizations/Screens Referrals
Newborn Metabolic Screen: ❏ Pending ❏ NL ❏ ABN ____________ ❏ Referral Made: _______________________________________________________
Newborn Hearing Screening:❏ Pending ❏ Pass ❏ Fail F/U Next Visit: ___________________________________________________________
❏ Immunizations Reviewed: ❏ First HBV given Date:_________________ History and physical reviewed with resident at time of visit, agree with the diagnosis
of and treatment
Immunizations Ordered:
Provider Print Signature
❏ HBV
No. 1 of 7 ✔ or ❏
Instructions: If the action was taken or completed, the open box must be marked (❏ x ).
COPY FOR DC DOH
MR #: __________________________ WELL CHILD/0 to 1 MONTH
NAME DOB ❏ M DRUG ALLERGIES ❏ 1st Visit
❏ F
❏ Periodic Visit
Immunizations/Screens Referrals
Newborn Metabolic Screen: ❏ Pending ❏ NL ❏ ABN ____________ ❏ Referral Made: _______________________________________________________
Newborn Hearing Screening:❏ Pending ❏ Pass ❏ Fail F/U Next Visit: ___________________________________________________________
❏ Immunizations Reviewed: ❏ First HBV given Date:_________________ History and physical reviewed with resident at time of visit, agree with the diagnosis
of and treatment
Immunizations Ordered:
Provider Print Signature
❏ HBV
No. 1 of 7 ✔ or ❏
Instructions: If the action was taken or completed, the open box must be marked (❏ x ).
WELL CHILD/0 to 1 MONTH
ADDITIONAL COMMENTS: ________________________________________________________________________________
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INSTRUCTIONS
✔ or ❏).
If the action was taken or completed, the open box must be marked (❏ x
If the child is enrolled in Medicaid, please be sure to print and sign your name in the space provided and fax or mail the completed form to:
HEALTHCHECK REGISTRY
POST OFFICE BOX 77498
WASHINGTON, DC 20013-7749
FAX: (202) 541-5907
For further information on HealthCheck or Bright Futures go to www.brightfutures.org/healthcheck.html