PREVENTIVE CARE ASSESSMENT FORM FOR CHILDREN AND ADOLESCENTS
Completed Form must be placed in record (if EMR scanned in record)
Patient Name: _________________________________________
D.O.B: ____/____/_____
PCP Name: ___________________________________________
Weight Assessment and Counseling for Nutrition and Physical Activity (WCC)
Age: 3-17 years
Please enter data from the visit:
1. BMI Percentile:
 Height_____
 Weight_____
 BMI percentile _______ or BMI percentile plotted on an age-growth chart: Y / N (if yes attach age-growth
chart; please note that a percentile range or threshold is not HEDIS acceptable)
2. Assessment, counseling or education on nutrition (at least one of the following):
• I discussed the child’s current nutrition behaviors (e.g., eating habits, dieting behaviors) with parent/child at
today’s visit Y / N
• I provided counseling on the child’s nutrition to the parent/child at today’s visit Y / N
• I provided educational materials to the parent/child to assist with the child’s nutrition during today’s visit
Y/N
• I provided anticipatory guidance for the child’s nutrition to the child/parent at today’s visit Y / N I
provided weight/obesity counseling for the child to the parent/child during today’s visit Y / N
3. Assessment, counseling or education on physical activity/exercise (at least one of the following):
•
I discussed the child’s current physical activity behaviors (e.g., exercise routine, participation in sports
activities, exam for sports participation) with parent/child at today’s visit Y / N
•
I provided counseling on the child’s physical activity to the parent/child at today’s visit Y / N I
provided educational materials to the parent/child related to the child’s physical activity during today’s visit Y
/N
•
I provided anticipatory guidance for the child’s physical activity to the child/parent at today’s visit Y /
N I provided weight/obesity counseling for the child to the parent/child during today’s visit Y / N
Is there a diagnosis of pregnancy during the measurement year?
Date of diagnosis: __/__/__
PCP Signature ________________________________ Date of Visit ____/____/______ Comments:
______________________________________________________________________________
FCNY APC_ WCC FORM_ QHCM2017
PREVENTIVE CARE ASSESSMENT FORM FOR CHILDREN AND ADOLESCENTS
Completed Form must be placed in record (if EMR scanned in record)
Patient Name: _________________________________________
D.O.B: ____/____/_____
PCP Name: ___________________________________________
Adolescent Preventive Care (APC) Age:
12-17 years
1. Assessment or counseling or education on risk behaviors and preventive actions associated with sexual activity
(at least one of the following):
• I assessed the adolescent’s current behaviors (e.g., abstinent, sexually active) at today’s visit Y / N
• I provided counseling on HIV, STIs, or teen pregnancy at today’s visit Y / N
• I discussed “sex” and “safe dating” at today’s visit Y / N
• I provided educational materials to the adolescent, specifically geared towards risk behaviors and preventive
actions at today’s visit Y / N
2. Assessment or counseling or education for depression (at least one of the following):
• I used a depression questionnaire (such as Beck’s Depression Inventory, Patient Health Questionnaire, Reynolds
Adolescent Depression Screen, Mood and Feelings Questionnaire) at today’s visit Y / N
• I assessed the patient’s presence or absence of depressive symptoms (sad, down, hopeless or suicidal ideation,
loss of interest, poor appetite, change in sleep pattern and difficulty concentrating) at today’s visit Y / N
• I assessed the presence or absence of depression (e.g., “denies symptoms of depression”, “depression symptomsnone or risks noted”, “depression-yes or no”) at today’s visit Y / N
• The adolescent has a diagnosis of depression during the measurement year Y / N
• The adolescent is being treated for depression in the measurement year Y / N
• I provided counseling on the symptoms of depression and/or where to get help during today’s visit Y / N
• I educated the adolescent on the symptoms, treatment or strategies to deal with depression at today’s visit Y / N
• I provided educational material to the adolescent, specifically geared towards the symptoms of depression,
treatment alternatives, red flag warnings and where to get help Y / N
3. Assessment or counseling or education about the risk of tobacco usage (at least one of the following):
• I assessed the adolescent’s current or past behavior regarding tobacco use at today’s visit Y / N
• I provided counseling on tobacco use and the problems it can cause during today’s visit Y / N
• I provided educational materials to the adolescent, pertaining to tobacco use at today’s visit Y / N
• I provided anticipatory guidance to the adolescent related to tobacco use during today’s visit Y / N
• I discussed the harmful effects of being exposed to secondhand smoke with the parent/adolescent during today’s
visit Y / N
4. Assessment or counseling or education about the risk of substance use (including alcohol and excluding
tobacco) (at least one of the following):
• I assessed the adolescent’s current or past behavior regarding substance use or alcohol use during today’s visit Y
/N
• I provided counseling on alcohol use/substance use and the problems they can cause during today’s visit Y / N
• I provided educational materials to the adolescent, pertaining to substance and alcohol use (not tobacco) during
today’s visit Y / N
• I provided anticipatory guidance to the adolescent related to substance use and alcohol use during today’s visit Y
/N
PCP Signature ______________________________________
Date of Visit ____/____/_____
Comments: ______________________________________________________________________________
FCNY APC_ WCC FORM_ QHCM2017