Happy Twelfth Birthday
Please call your child’s provider and schedule a yearly
check-up. As part of the exam your child should receive their
recommended immunizations as well as any catch up that is
needed. By the 13th birthday, your child should have
had the shots listed below:
•2 MMR (Measles, Mumps, Rubella)
•3 Hepatitis B
•1 Varicella (Chickenpox), if your child has not had the disease.
When you take your child in for an exam, please take this form
with you and ask the provider to fill in the lower part and fax
the entire page back to us. We will send your child a $10 Walmart
gift card after we receive the form from your child’s provider.
Child’s Name:
Child’s Molina Healthcare ID #:
Address:
Apt #:
Zip:
City:
Phone Number with Area Code:
Child’s Birth Date:
Parent/ Guardian Email Address:
May we contact you by email? ☐ Yes ☐ No
Provider: Please complete both the bottom and the back of this form and fax BOTH sides to
(800) 461-3234. For your convenience, the back of this form contains the age specific EPSDT form.
A copy of the medical record can be faxed as a substitute for the EPSDT form.
Well Child Exam Date:
Provider’s Name:
Provider’s Signature:
Provider’s Phone Number:
MRC Part# 12-1071
Approvals: MHW- 9/11/12 HCA- N/A
www.MolinaHealthcare.com
26485WA0812
WELL CHILD EXAM - LATE
CHILDHOOD: 12 YEARS
DATE
(Meets EPSDT Guidelines)
LATE CHILDHOOD: 12 YEARS
PARENT AND CHILD TO
COMPLETE ABOUT CHILD
CHILD'S NAME
BROUGHT IN BY
ALLERGIES
DATE OF BIRTH
CURRENT MEDICATIONS
ILLNESSES/ACCIDENTS/PROBLEMS/CONCERNS SINCE LAST VISIT
YES NO
My child has one or more close friends.
My child gets some physical activity every day.
HEIGHT CM/IN. PERCENTILE
BLOOD PRESSURE
Diet
Sleep
Review of family history
MHZ
4000
R
Review Immunization Record
TB
Dental Referral
Hct/Hgb
Health Education: (Check all discussed/handouts given)
L
Development
After School Supervision
2000
Nutrition
1000
Regular Physical Activity
Discipline
L 20/
R 20/
N A
Acne
Seat Belt
Dental Care
Sex
Helmets
Smoking/Passive Smoke
Reading/Homework
500
Vision
My child seems rested when he/she awakens.
My child handles stress, anger, frustration appropriately.
Review of systems
Hearing
NO
My child is doing well in school.
WEIGHT KG./OZ. PERCENTILE
Screening:
YES
My child eats breakfast every day.
TODAY I HAVE A QUESTION ABOUT:
Puberty/Menses Onset
Drugs/Alcohol
Other: BMI %
Behavior
Social/Emotional
Assessment/Plan:
Mental Health
Physical:
General appearance
Skin
Head
Eyes
Ears
Nose
Oropharynx/Teeth
Neck
Nodes
N
A
Chest
Lungs
Cardiovascular/Pulses
Abdomen
Genitalia
Spine
Extremities
Neurologic
Gait
N
A
Describe abnormal findings and comments:
IMMUNIZATIONS GIVEN
REFERRALS
NEXT VISIT: 14 YEARS OF AGE
HEALTH PROVIDER SIGNATURE
HEALTH PROVIDER NAME
HEALTH PROVIDER ADDRESS
DSHS 13-685D(X) (REV. 08/2004) - TRANSLATIONS
SEE DICTATION
DISTRIBUTION: White - Physician
Yellow - Parent/Guardian
LATE CHILDHOOD: 12 YEARS