Age 1-12 years, comprehensive health assessment of a child.
 
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What is the mailing address of individual/individuals’ source/sources of this medical history?
 
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_________________________<br><br>
 
How is this individual related to the child?
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_________________________<br><br>
 
Where does this child (with name, date of birth mentioned) live at this point?
 
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_________________________<br><br>
 
How long has the child lived at this location?
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_________________________<br><br>
 
Who is the caregiver for the child at this location?
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_________________________<br><br>
What is the profile of the caregiver at this location?
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_________________________<br><br>
 
What best describes the caregiver for this individual?
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_________________________<br><br>
Mother<br>
Father<br>
Foster mother<br>
Foster father<br>
Legal guardian<br>
Other (specify)<br><br>
 
Feeding History<br><br>
 
Who feeds the child every day?
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_________________________<br><br>
 
Has the caregiver taken parenting classes?
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_________________________<br><br>
 
What food does the child get every day?
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_________________________<br><br>
 
How many times is the child fed every day?
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_________________________<br><br>
 
How long does the child’s feeding last? 
 
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_________________________<br><br>
 
Developmental History<br><br>
 
Do you know the birth weight of this child?
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_________________________<br><br>
 
What was the birth weight of this child?
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_________________________<br><br>
 
 
What is the weight record of the child every six months after birth?
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_________________________<br><br>
 
What is the record of the yearly length of the child? 
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_________________________<br><br>
 

CPT Codes for Developmental Screening<br><br>

1. Pediatric Patient at Preventive Care Visit<br><br>

2. Perform Surveillance<br><br>

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

3. Does Surveillance Demonstrate Risk?<br><br>

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

5a and 5b: Administer Screening Tool<br><br>

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

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

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

9. Is a Developmental Disorder Identified?<br><br>
10. Identify as a Child With Special Health Care Needs and Initiate Chronic-Condition Management<br>
Choosing Developmental Screening Tools<br>
Incorporating Surveillance and Screening in the Medical Home

 
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