Fillable North Carolina Department of Health and Human Services (North Carolina)

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North Carolina Department of Health and Human Services (North Carolina)

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North Carolina Department of Health and Human Services | Division of Social Services
Health Summary Form – Well-Visit
DSS-5209 (Created 02/2016)
Child Welfare Services
Page 1 of 2
Well-Visit for Infants/Children/Youth in DSS Custody*
Instructions: Provider completes this form at each well visit or provides a summary containing the requested information.
Copy given to______________________ (caregiver) on____/____/_________by____________________________
Date of Visit: Patient’s Name: D.O.B: / /
Patient’s Medicaid ID Number: __________________________________________________
Physical Examination: ATTACH
Visit Summary with vitals, growth parameters and exam
findings
Screenings:
Vision: Pass____ Fail____ With glasses? Yes ____ No____ Referral? _______________________
Hearing: Pass____ Fail____
Development (circle one): ASQ/PEDS/MCHAT/PSC/Bright Futures Supplemental-Adolescent:
No Concerns_____ At Risk/Concerns_____
Specific Social-Emotional Screen: (e.g. ASQ-SE, ECSA, PHQ-9, Vanderbilt, SCARED)
No Concerns_____ At Risk/Concerns_____
Current health conditions/issues (acute/chronic): Medications provided/prescribed:
_________________________________________ _____________________________
_________________________________________ _____________________________
_________________________________________ _____________________________
Other concerns (home, school, community):________________________________________
____________________________________________________________________________
____________________________________________________________________________
Immunizations (administered this visit): Allergies:
__________________________________________ _____________________________
__________________________________________ _____________________________
__________________________________________ _____________________________
North Carolina Department of Health and Human Services | Division of Social Services
Health Summary Form – Well-Visit
DSS-5209 (Created 02/2016)
Child Welfare Services
Page 2 of 2
Referrals (specialty care/CC4C/home visits): Addressing what need:
__________________________________________ _____________________________
__________________________________________ _____________________________
__________________________________________ _____________________________
PSYCHOTROPIC MEDICATION REVIEW REQUESTED: YES NO
Treatment plan (follow-up appointment/labs/testing/needed immunizations):
_________________________________________________________________________________
_________________________________________________________________________________
Comments or instructions for DSS/caregivers/school personnel:
_________________________________________________________________________________
_________________________________________________________________________________
Next Well-Visit
date/time: ____________________________
Provider name: ____________________________________
Provider signature: _________________________________
THIS FORM & VISIT SUMMARY FAXED/SENT TO DSS & CCNC/CC4C CARE MANAGER:
DATE: INITIALS:
*Adapted from AAP’s Healthy Foster Care America Health Summary Form
(stamp)
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North Carolina Department of Health and Human Services (North Carolina)

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Completed 31 January 2022

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