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
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