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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 - Comprehensive
DSS-5208 (Created 02/2016)
Child Welfare Services
Page 1 of 6
30-day Comprehensive Visit for Infants/Children/Youth in DSS Custody
Instructions: Providers complete this form at the time of the comprehensive medical appointment. Please attach summary of visit
and enter any information on the form that is not included in the summary.
Date of Visit: / / Patient’s Name: D.O.B: / /
Patient’s Medicaid ID Number: _________________________________________________________
COUNTY DSS CONTACT
Name______________________________________________________________________________
Phone ________________________________Fax__________________________________________
Email_________________________________________County________________________________
MEDICAL HISTORY
Birth History
Location of birth (if hospital, name and location) _______________________________________
BW_________________ Term___ Preterm____Gestation_______wks
Prenatal and perinatal risks ______________________________________________________
NICU:
YES NO Detail______________________________________________________
Acute illness or other health needs_______________________________________________________
___________________________________________________________________________________
Does the child have signs/symptoms of any communicable disease (i.e. hepatitis, TB, lice) that would
pose a risk of transmission in a household setting? YES NO UNKNOWN
If yes, describe: ______________________________________________________________________
___________________________________________________________________________________
Chronic physical or mental health conditions (e.g., asthma, diabetes) Attach copy of the care plan _____
___________________________________________________________________________________
Surgery/hospitalizations/ER visits (when/where/why) _________________________________________
___________________________________________________________________________________
North Carolina Department of Health and Human Services | Division of Social Services
Health Summary Form - Comprehensive
DSS-5208 (Created 02/2016)
Child Welfare Services
Page 2 of 6
Past injuries (what; when) ______________________________________________________________
___________________________________________________________________________________
Allergies/drug sensitivities (with type of reaction)_____________________________________________
___________________________________________________________________________________
Current medications Dosage Why prescribed Need refill?
________________ _________ _____________
YES NO
________________ _________ _____________
YES NO
________________ _________ _____________
YES NO
________________ _________ _____________
YES NO
________________ _________ _____________
YES NO
Medical equipment/supplies required______________________________________________________
Nutritional assessment (diet/formula and any special needs) ___________________________________
VISION, HEARING
Visual impairment YES NO
Glasses/contacts required?
YES NO
Hearing impairment
YES NO
Hearing aid or cochlear implant
YES NO Detail________________________________
ORAL HEALTH
Dental home
YES NO
Dentist ________________________ Most recent visit ________________
Current dental problems _________________________________________________________
Dental/oral health appointment scheduled____________________________________________
DEVELOPMENTAL HISTORY- Attach screening records and growth chart(s)
o ASQ-3 (Ages and Stages Questionnaire) or PEDS (age 0-5)
o PSC (Pediatric Symptom Checklist) (age 6-10)
o Bright Futures Supp. Questionnaire or PSC-Y (completed by adolescent, age 11-21)
North Carolina Department of Health and Human Services | Division of Social Services
Health Summary Form - Comprehensive
DSS-5208 (Created 02/2016)
Child Welfare Services
Page 3 of 6
Disability/ delay/concern:
Cognitive/learning__________________________________________________________________
Social-emotional___________________________________________________________________
Speech/language__________________________________________________________________
Fine motor________________________________________________________________________
Gross motor_______________________________________________________________________
None
Intervention history: Current/on-going: Past:
Speech & language therapy__________________________________________________________
Occupational therapy________________________________________________________________
Physical therapy ___________________________________________________________________
Results of Evaluation(s):_______________________________________________ (Attach report(s))
For ages birth-3: (If available, attach CDSA evaluation and Individualized Family Service Plan (IFSP)
Referral to Care Coordination for Children (CC4C)
YES NO
Referral to Early Intervention (Infant-Toddler Program)
YES NO
Date of evaluation by the Children’s Developmental Services Agency (CDSA) _____________________
For ages 3-5: (If available, attach Individualized Education Plan (IEP))
Referral to Care Coordination for Children (CC4C):
YES NO
Referral to the Preschool Early Intervention Program:
YES NO
Medical equipment and assistive technology:
YES NO Detail ___________________________
BEHAVIORAL/MENTAL HEALTH, SUBSTANCE ABUSE
(ASQ-SE, ECSA, SDQ, CESDC, SCARED, CRAFFT, and/or PHQ-9 for Adolescents, etc.)
Concerns___________________________________________________________________________
Screening results _____________________________________________________________________
Diagnosis
YES NO Detail________________________________________________________
Intervention and treatment history________________________________________________________
North Carolina Department of Health and Human Services | Division of Social Services
Health Summary Form - Comprehensive
DSS-5208 (Created 02/2016)
Child Welfare Services
Page 4 of 6
EDUCATION (If available, attach Individualized Education Plan (IEP) or Section 504 Plan)
Child care or preschool________________________________________________________________
School_____________________________________ Grade________ Grades repeated____________
Attendance problems? _______Reason___________________________________________________
In- or out- of school suspension:
YES NO Most recent? __________ How often? ___________
Has the child received counseling at school?
YES NO _________________________________
Learning Issues:
Learning disability
ADHD
Dysgraphia
Intellectual disability
Other
IEP? YES NO; 504 Plan? YES NO; Other accommodations/equipment needs at school?
___________________________________________________________________________________
Extracurricular activities________________________________________________________________
FAMILY AND SOCIAL HISTORY
Provider comments--genetic/hereditary risk or in utero exposure________________________________
___________________________________________________________________________________
Provider comments--current placement and visitation plan_____________________________________
___________________________________________________________________________________
EVALUATION
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-SW, ECSA, PHQ-9, Vanderbilt, SCARED)
No Concerns ______ At Risk/Concerns ______
North Carolina Department of Health and Human Services | Division of Social Services
Health Summary Form - Comprehensive
DSS-5208 (Created 02/2016)
Child Welfare Services
Page 5 of 6
Social/behavioral assessment (by integrated mental health professional, if applicable)
___________________________________________________________________________________
___________________________________________________________________________________
Overall assessment and diagnoses_______________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
PLAN/RECOMMENDATIONS
Follow-up treatment(s)/interventions for current health conditions including any labs, testing, or
evaluation with dates/times_____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Referrals for specialist care, mental health, oral health or developmental services with dates/times
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
PLAN/RECOMMENDATIONS CONTINUED
Medications provided and/or prescribed today_______________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Immunizations administered today________________________________________________________
___________________________________________________________________________________
Immunizations still needed, if any ________________________________________________________
___________________________________________________________________________________
Limitations on physical activity___________________________________________________________
___________________________________________________________________________________
Diet/formula/WIC_____________________________________________________________________
___________________________________________________________________________________
North Carolina Department of Health and Human Services | Division of Social Services
Health Summary Form - Comprehensive
DSS-5208 (Created 02/2016)
Child Welfare Services
Page 6 of 6
Special instructions for school and child care staff related to medications, allergies, diet______________
___________________________________________________________________________________
Special instructions for foster parents/DSS contact___________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Well-Visit scheduled for (date/time):
____/_____/______ _____: ______AM/PM
Evaluation Team:
Primary Care Provider: ____________________________________________________________
____________________________________________________________
Behavioral Health Provider: ____________________________________________________________
____________________________________________________________
Specialty Providers: ____________________________________________________________
Others: ____________________________________________________________
ATTACHMENTS:
Visit Summary (EHR print-out)
Immunization Record
Age-appropriate developmental screening record, including growth record
Screenings/measures to evaluate social-emotional, behavioral concerns
Discharge summaries from hospitals from birth and other hospitalizations
Care plans for asthma / diabetes / other chronic health conditions
Medical records related to chronic health conditions, medications, or allergies
Therapy or specialty provider reports (examples: speech, audiology, mental health)
THIS FORM & ATTACHMENTS FAXED/SENT TO DSS & CCNC/CC4C CARE MANAGER:
DATE: _____________________
INITIALS: __________________
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North Carolina Department of Health and Human Services (North Carolina)

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Completed 11 November 2021

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