Age 1-12 years, comprehensive health assessment of a child.
What is the mailing address of individual/individuals’ source/sources of this medical history?

_________________________

How is this individual related to the child?

_________________________

Where does this child (with name, date of birth mentioned) live at this point?

_________________________

How long has the child lived at this location?

_________________________

Who is the caregiver for the child at this location?

_________________________

What is the profile of the caregiver at this location?

_________________________

What best describes the caregiver for this individual?

_________________________

Mother
Father
Foster mother
Foster father
Legal guardian
Other (specify)

Feeding History

Who feeds the child every day?

_________________________

Has the caregiver taken parenting classes?

_________________________

What food does the child get every day?

_________________________

How many times is the child fed every day?

_________________________

How long does the child’s feeding last?

_________________________

Developmental History

Do you know the birth weight of this child?

_________________________

What was the birth weight of this child?

_________________________

What is the weight record of the child every six months after birth?

_________________________

What is the record of the yearly length of the child?

_________________________

CPT Codes for Developmental Screening

1. Pediatric Patient at Preventive Care Visit

2. Perform Surveillance

Eliciting and Attending to the Parents' Concerns
Maintaining a Developmental History
“What changes have you seen in your child's development since our last visit?”
Making Accurate and Informed Observations of the Child
Identifying the Presence of Risk and Protective Factors
Documenting the Process and Findings

3. Does Surveillance Demonstrate Risk?

4. Is This a 9-, 18-, or 30-Month* Visit?

5a and 5b: Administer Screening Tool

6a and 6b: Are the Screening-Tool Results Positive/Concerning?

7. Make Referrals for Developmental and Medical Evaluations and Early
Developmental Intervention/Early Childhood Services

8. Developmental and Medical Evaluations
Developmental Evaluation
Medical Evaluation
Early Developmental Intervention/Early Childhood Services

9. Is a Developmental Disorder Identified?

10. Identify as a Child With Special Health Care Needs and Initiate Chronic-Condition Management
Choosing Developmental Screening Tools
Incorporating Surveillance and Screening in the Medical Home