DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1002 (07/08)
STATE OF WISCONSIN
HEALTHCHECK INDIVIDUAL HEALTH HISTORY
Current Medical Assistance I.D. Number Per Code
Fill out one form for each person screened
Name - Patient Address Patient Telephone Patient Birth Date Patient (Month / Day / Year) School and Grade or Occupation Patient
Date Completed (Month / Day / Year)
Name - Parent or Guardian Address Parent or Guardian Telephone Parent or Guardian
Name and Address - Physician Name and Address - Dentist
GENERAL HEALTH - Answer for All Ages
Office Use 1 2 3 4 5 Yes No Don't Know Has it been more than 12 months since this person had a general checkup by a physician? Has it been more than 12 months since a physician examined this person because of illness or injury? Has it been more than 12 months since this person had a general checkup by a dentist? Has it been more than 12 months since a dentist examined this person because of illness or injury? Is there anything about this person's health, growth or development that you are concerned or worried about? If YES, explain. Does this person always use a seatbelt or car seat in an automobile?
6 Office Use 7 8 9 10 11 12 13 14 15 16 17 18 19 Don't Know
DID THIS PERSON EVER HAVE OR DOES THIS PERSON NOW HAVE ANY OF THE FOLLOWING?
Yes No Office Use Unexplained fever Poor appetite or feeding problem Loss of weight Loss of consciousness, fainting Head injury Seizure, convulsions, fits Frequent headache Eye trouble Earaches, draining ears Frequent nosebleeds Chronic cough Hearing problems Constipation 20 21 22 23 24 25 26 27 28 29 30 31 Yes No Don't Know Vomiting or diarrhea Wheezing or noisy breathing Swollen joints Heart murmur Frequent stomach aches Blood in bowel movements Bladder, kidney, or urinary problems Blood in urine Rashes, eczema, hives, skin problems Many bruises or bleedings Frequent stumbling, falling Frequent colds or infections
HEALTHCHECK INDIVIDUAL HEALTH HISTORY F-1002 (07/08)
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Office Use 32
Yes
No
Don't Know
HAS THIS PERSON HAD ANY OF THE FOLLOWING?
Rubella (German measles) Measles (Red) Mumps Rheumatic Fever Did or does this person have allergies? If YES, describe.
33
34
Did or does this person have asthma?
35
Has this person had any serious accidents? If YES, describe.
36
Has this person had any hospitalizations, operations, major illness? If YES, describe.
37
Does this person now have any problems which you feel, or which a physician has told you, may be related to any one of the conditions 7 36? If YES, describe.
38
Does this person OFTEN eat things which are not usually considered to be food? (Example: dirt, paint chips, crayons, clay, starch, newspaper.) If YES, describe.
39 40 41 42 43 44
Does this person have problems with toileting or toilet training? Does this person get along with family members and playmates? Does this person have difficulty learning? Does this person get into trouble in school or dislike school? Has this person taken prescription medicines in the last 12 months? For what? Has this person taken non-prescription medicines in the last 12 months? (Example: aspirin, antihistamines, vitamins, food supplements.) If so, what medications?
45 46 47
Has this person ever had a positive reaction to a tuberculosis test? Referred for Adolescent Review. ANSWER FOR FEMALES BORN BEFORE 1972: Did the mother of this person take any medications to prevent miscarriage during this pregnancy?
IMMUNIZATION HISTORY: List the immunizations and dates received.
Type (Recommended Dose) None Dose 1 Dose 2 Dose 3 Dose 4 Dose 5
HEALTHCHECK INDIVIDUAL HEALTH HISTORY F-1002 (07/08)
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BEHAVIORAL / EMOTIONAL HEALTH
Office Use 47 Yes No Don't Know Does this person have a history of either: n n Behavioral or emotional problems OR Treatment for behavior or emotional problems at a clinic or hospital? If YES for any, explain.
48
Has anyone in this person's family ever been treated or hospitalized for emotional problems such as depression, anxiety, mood swings, suicide attempts, or alcohol or drug abuse? If YES for any, explain.
49
Has this person ever abused alcohol and/or drugs? If YES, explain.
50
Has this person ever felt hopeless or depressed had unexplained crying spells planned or attempted suicide had peculiar or bizarre thoughts had trouble eating or sleeping (too much or too little) had an excess of energy or activity felt like hurting him/her self displayed reckless or dangerous behavior heard things no one else around them heard show inappropriate emotions (reactions that don't make sense for the situation)
51
Does this person have any of these problems at school? poor grades difficulty in making friends frequent suspensions from schools fighting or arguing with peers or teachers frequently lying or stealing frequently cutting classes or playing hooky
52
Has this person had any of the following problems at home or in the community? withdrawing socially (doesn't want to be around other people) lying or stealing arguing or fighting with peers or brothers or sisters clinging excessively to a parent, teacher, or other person running away from home problems with police refusing to follow instructions from parents, or obey the house rules, etc.
Criteria for Referral for Further Assessment 47. and 49. Refer for a psychiatric assessment if there is a positive response. 48. Refer only if referred criteria are met for any other question. 50. Refer for a psychiatric assessment if any responses are checked. 51. and 52 Refer for a psychiatric assessment if two or more responses are checked.
HEALTHCHECK INDIVIDUAL HEALTH HISTORY F-1002 (07/08)
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PREGNANCY & DEVELOPMENT
Answer for all Ages
BIRTH ORDER of this person. Indicate by placing a check mark in the appropriate box whether this person was the first, second, etc. Do not count stillborn brothers or sisters. 1st 2nd 3rd 4th Check one Check one 5th Under 17 Under 17 6th 7th 17-39 17-39 8th 40 and over 40 and over 9th 10th or over Unknown Unknown
MOTHER'S AGE AT THIS BIRTH FATHER'S AGE AT THIS BIRTH 53 Yes No Don't Know
MOTHER'S PREGNANCY HISTORY-Answer only for children UNDER 6 YEARS Was there any bleeding during this pregnancy? Was the baby born early? If so, how many weeks? Was there other difficulty or illness during this pregnancy? (Examples: rubella or german measles, high blood pressure, high blood sugar, sexually transmitted diseases, etc.) If YES, describe. Were any X-rays taken during pregnancy? Were any prescription or other drugs taken during pregnancy? (Examples: tranquilizers, antibiotics, sedatives, medicines for vomiting, medicines shot or oral to prevent miscarriage or bleeding.) If YES, describe. Were any non-prescription medications taken during pregnancy? (Examples: vitamins, iron supplements, frequent aspirin, etc.) If YES, describe. Was there anything unusual about the labor or delivery? If YES, describe.
54 Birth Weight: _____lbs. _____ozs.
DEVELOPMENTAL MILESTONES-Answer only for children UNDER 6 YEARS Length ______________ inches
Check the appropriate time this child did each of the following. Follow object with eyes Not yet Before 1 month 1 - 4 months After 4 months Roll over Not yet Before 2 months 2 - 5 months After 5 months Turn to voice Not yet Before 3 months 3 - 8 months After 8 months Sit alone Not yet Before 5 months 5 - 9 months After 9 months Act shy with strangers Not yet Before 5 months 5 - 10 months After 10 months
Walk alone Not yet Before 11 months 11 - 15 months After 15 months
Speak single word Not yet Before 9 months 9 - 12 months After 12 months
Speak simple sentences Not yet Before 20 months 20 mo. - 2 ½ years After 2 ½ years
Eat finger food alone Not yet Before 2 years After 2 years
Use cup alone Not yet Before 2 years After 2 years
Permission is hereby granted for health screening for early detection of health problems for ________________________________________ (Name of Patient) and for the release of resulting information to appropriate health care providers and health authorities. Permission is also granted to such health care providers and health authorities to release information to personnel conducting this health-screening program.
_____________________________________________ SIGNATURE
______________________________ Relationship to Patient
____________________ Date Signed