Health History
CHILD AND TEEN CHECKUPS (C&TC) FACT SHEET FOR PRIMARY CARE PROVIDERS
C&TC Requirements
General
A complete, detailed initial health history must
be obtained according to medical standards for
new C&TC clients. Information can be obtained
from the child, parent, guardian or an adult who
is familiar with the child’s health.
The history must include information on sexual
development, lead and tuberculosis exposure,
nutritional intake, chemical abuse, and social,
emotional, and mental health status.
An interim history should be collected at each
subsequent C&TC visit in order to identify any
previously undetected issues that may impact
the child’s health and development.
Personnel
The health history can be completed by the
parent/guardian or collected by a medical
assistant or other trained staff using a health
history form.
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Identification of mental health needs or
risks and history of trauma,
Information on sexual development and
maturation,
Risk of exposure to lead, tuberculosis, and
sexually transmitted infections (STI),
Nutritional intake,
Chemical use, abuse, and risks,
Medications (prescription and nonprescription) and supplements.
Developmental History
Review findings from previous developmental
surveillance and screenings, and follow up on
previous referrals for evaluation and services.
Ask about any parent/caregiver concerns
regarding the child’s development or behavior.
For more information, refer to the
Developmental Surveillance and Screening
C&TC Fact Sheet (www.health.state.mn.us).
Mental Health History
Documentation should include all normal and
abnormal findings for physical health, mental
health, and developmental history. For
documentation examples, refer to the C&TC
Provider Documentation Forms
(www.dhs.state.mn.us).
Ask questions regarding psychosocial problems
or concerns. Adverse Childhood Experiences
(ACEs) can affect a child’s mental and physical
health for a lifetime (American Academy of
Pediatrics, 2014). It is important to ask about a
child’s exposure to trauma and stress because
emotional and behavioral concerns often
develop in children as a response to social
conditions. The American Academy of Pediatrics
recommendations emphasize using
standardized screening instruments to facilitate
recognition and referral of social-emotional
problems as part of routine primary care visits.
For more information, refer to the SocialEmotional (0-5 years) and Mental Health
Screening (6-21 Years) C&TC Fact Sheets
(www.health.state.mn.us).
Procedure
Chemical Use History
Review and interpretation of the health history
should be completed by licensed professional
health care staff (including Physician, Nurse
Practitioner, Physician Assistant, or a qualified
Public Health Nurse who has completed the 3day C&TC Comprehensive Training provided by
the Minnesota Department of Health).
Documentation
Health history includes but is not limited to:
▪ Complete medical and family history,
Inquire about the child or adolescent’s use of
tobacco, alcohol, and other substances with
HEALTH HISTORY C&TC FACT SHEET
potential for abuse, including use of over-thecounter or prescription drugs for non-medical
purposes.
Use available recommended instruments to
assess for alcohol and drug use disorders, such
as the CRAFFT (www.ceasar-boston.org) (Levy,
Williams, & Committee on Substance Use and
Prevention, 2016). Additionally, the Alcohol
Screening and Brief Intervention for youth - A
Practitioner's Guide (www.niaaa.nih.gov) can be
used to identify youth at risk for alcohol related
problems. Refer to the Substance Use
Assessment C&TC Fact Sheet
(www.health.state.mn.us).
It is important that clinicians provide
interventions to prevent initiation of tobacco
use (U.S. Preventive Services Task Force, 2013).
In 2013, more than one in five high school
students reported using a tobacco product in
the past 30 days (Centers for Disease Control
and Prevention, 2014). Parents or caregivers
identified as tobacco users should be advised to
quit and be given resources to do so. Brief
counseling in the clinical setting can impact
tobacco use. For more information, Quit
Smoking (www.cdc.gov). Free tobacco cessation
services are available in Minnesota through
QuitPlan Services (www.health.state.mn.us).
Nutritional History
Include a review of an individual’s nutritional
status and dietary practices to identify unusual,
deficient or excessive eating habits, dietary
quality and quantity, and meal patterns. Refer
all children ages birth to five years to the
Women, Infants and Children (WIC) Program
(www.health.state.mn.us).
When screening indicates a nutritional risk
condition, the individual must receive further
assessment and nutritional counseling. As
appropriate, refer children, teens, and young
adults to a registered dietician or licensed
nutritionist. To find a dietician or nutritionist by
zip code, go to the Academy of Nutrition and
Dietetics Find an Expert (www.eatright.org).
When appropriate, refer families to food and
nutrition resources including the Supplemental
2
Nutrition Assistance Program (SNAP)
(www.mn.gov/dhs).
Resources
American Academy of Pediatrics (AAP)
▪ Bright Futures Guidelines and Pocket Guide
(www.brightfutures.aap.org)
▪ Trauma Guide (www.aap.org)
Minnesota Department of Health (MDH)
▪ Child and Teen Checkups (C&TC)
(www.health.state.mn.us)
Minnesota Department of Human Services
(DHS)
▪ Minnesota Health Care Programs Provider
Manual, C&TC Section (www.dhs.state.mn)
References
American Academy of Pediatrics. (2014). Retrieved from
Adverse childhood experiences and the lifelong
consequences of trauma: www.aap.org/en-us/advocacyand-policy/aap-health-initiatives/healthy-foster-careamerica/Pages/Trauma-Guide.aspx
Centers for Disease Control and Prevention. (2014).
Tobacco use among middle and high school students –
United States, 2013. Morbidity and Mortality Weekly
Report, 63(45), 1021-1026.
Levy, S. J., Williams, J. F., & Committee on Substance Use
and Prevention. (2016). Substance Use Screening, Brief
Intervention, and Referral to Treatment. Pediatrics, 20161211.
U.S. Preventive Services Task Force. (2013). Tobacco Use in
Children and Adolescents: Primary Care Interventions.
Retrieved from Annals of Internal Medicine and Pediatrics:
www.uspreventiveservicestaskforce.org
For More Information
Minnesota Department of Health
Child and Teen Checkups Program
PO Box 64882,
St. Paul, MN 55164-0882
(phone) 651-201-3760
[email protected]
www.health.state.mn.us
Revised: 1/2017
To obtain this information in a different format, call:
651-201-3760.