Arkansas Departmentof HumanServices

DivisionofChildCareandEarlyChildhoodEducation

To Parent orGuardian:

Inordertoprovidethebestlearningexperienceforyourchild,teachermustunderstandyourchild’shealthneeds.StateregulationsrequireanychildenrolledintheArkansasBetterChancePre-Kprogramtohaveawellchildcheck-up.Inaddition,thechildmustbecurrentonallrequiredimmunizations.Pleasecompletethispageoftheform,signitandgiveittoyourchild’sphysicianorlicensednursepractitioner.Onceformiscompletedandsigned on both sides, return the form to your Pre-K program.

Child’s Name(Last, First,Middle) / Child’sDateof Birth / Sex / Parent/GuardianName
Address, City andZip Code
Name ofPre-K ProgramWhereEnrolled / Pre-KProgramPhoneNumber
Type of Health Insurance
DARKidsADPrivateInsurance
DARKidsBDOther:

Part I– Tobecompleted by parent orguardian before well child screening.

Check answers tothe following questions.Explainany“yes” answers in thespace provided.

Yes / No
1. / D / D / Doyouhave anyconcernsaboutyourchild’sgeneralhealth?
2. / D / D / Hasyourchildbeendiagnosedwith anychronicdisease(suchasasthma or diabetes)?
3. / D / D / Doesyourchildhave any allergies(liketofood,medicine,dust)?
4. / D / D / Doesyourchildtakeanymedications(dailyoroccasionally)?
5. / D / D / Doesyourchildhave any problemswith vision,hearingorspeech?
6. / D / D / Hasyourchildhad any hospitalization,operation,majorillnessorinjury?
7. / D / D / Inthepast12months,hasyourchildexperienced any difficultywithwheezingornightcoughing?
8. / D / D / Inthepast12months,hasyourchildexperiencedexcessiveweightloss orweightgain?
9. / D / D / Hasyourchildhad a dentalexamination in thelast12months?
10. / D / D / Wouldyouliketodiscussanything aboutyourchild’shealthwith thehealthcareprovider?

Ifyouanswered“yes”to any question,pleaseexplainbelow. For illnessesorinjuries,includeyourchild’sageatthetime.

Question # / Explanation

Parent/Guardian PermissionandRelease:

I give mypermissionfortheinformation onthisformtobeusedinmeeting mychild’shealthandeducationalneedswhileenrolledintheArkansasBetterChanceprogram.

SignatureofParent/GuardianDate

ABC Form # 010(Eff. Date 07/01/15)

Child’s Name(Last, First,Middle) / Child’sDateof Birth / Sex / Parent/GuardianName

To HealthCareProfessional:

ThischildisenrolledintheArkansasBetterChancePre-K program.Stateregulationsrequire a comprehensivewellchildscreeningforallenrolledchildren. The DivisionofChildCareandEarly ChildhoodEducationrecommendsanEarlyPeriodicScreeningandDiagnosticTreatment(EPSDT)whichisage-appropriate. ForchildrenenrolledinARKids,thecostoftheEPSDTmaybe billedtoARKids A or B usingtheprocedurecodesbelow:

Patient Type / ARKIDSA / ARKIDS B
1-4years / 5-11years / 1-4years / 5-11years
New / 99382EPU1 / 99383EPU1 / 99382 / 99383
Established / 99382EPU2 / 99383EPU2 / 99382 / 99383

Part II – To be completed by Health CareProvider.Complete all sections and sign atthe bottom.

Weight / Height / BMI / Temp / Blood Pressure
lb. / %ile / in. / %ile / % / /

HistoryUpdate

DYes DNoAnychanges in patienthealthsincelastvisit? Explain:_

DYes DNoAnyfamily historyofheartdiseaseforanyone under55yearsofage?

DYes DNoAnyfamilyhistoryofabnormalcholesterol?

Health

DGoodappetiteDPickyorvariableeater

DDrinkslowfatmilkDBrushesteeth,seesdentist

DEncouragedietoffruitandvegetables

DLimitsfastfood

SocialandBehavioral

DParentsdisciplineappropriatelyDPraisedforgoodbehaviorDDressesself,helpsathomeDHasfriendsandplaymatesDTVandvideogamesarelimited

ScreeningandLaboratoryResults

Test / Result / Date / Comments if abnormal
Vision
Test type: / LR
Hearing
Test type:
TB
Risk: Yes / No
Hemoglobin
Risk: Yes / No
Cholesterol
Risk: Yes / No / mg/dL

Immunizations

DYes DNoAllimmunizationsarecurrent.

DYes DNoChildhashadallimmunizationspossibleatthistime.

Childneeds:DDTaP DIPV DHepB DHiB DMMR DVarivax D PCV-7atyears/months

ABC Form # 010(Eff. Date 07/01/15)

Referrals

DFollowupvisitneededin

weeks / months

ABC Form # 010(Eff. Date 07/01/15)

DReturncheckatyearsmonths

DNeedstoseedentist. Referraltobemadeby physicianornursepractitioner.

Impressions

DWellchild,normalgrowthanddevelopment

D

_,MD / DO/ NPDate_

ABC Form # 010(Eff. Date 07/01/15)