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REGION 2 PACKETELEMENTARY ENGLISHEPSDT/OPT/FLUORIDEFor more than 18 years Well Child, with its school partnerships, has helped parents identify many hidden health issuesthat need medical attention. Well Child offers yearly checkups and yearly eye exams at no cost to the school or district.These exams are the same as an annual visit to a primary provider or optometrist. You will be made aware of all findingsand given information about any recommendation for your child to have further health evaluation.Well Child Yearly Checkup Vision and hearing screeningsA complete head-to-toe physical exam (clothes lifted)Immunization reviewLab (blood work)-finger stickA complete history including developmental/behavioralscreeningsWell Vision Yearly Eye Exam Licensed optometrist conducts all examinationsOptometrist will determine any vision and eye health problemsIf clinically needed, your child's eyes may be dilated withparental permissionGlasses will be prescribed and provided when necessaryGlasses will be fitted to your child at schoolWell Child will bill your insurance carrier or managed care organization for the exam(s). For any questions regarding coverage orbenefits, please contact your insurance carrier.For annual checkups Well Child can be paid by the following:Tenn Care Insurance Plans AmerigroupBlueCareCoverKidsTennCare SelectUnited Health Care Community Plan Commercial Insurance PlansAetna Pittman and AssociatesBlueCross (Network P Only) TricareCigna United Health CareHumana Other plansKeystone WestFor annual vision exams, Well Child can be paid by the following insurance carriers: BlueCare CoverKids TennCare Select United Health Care Community Plan (March Vision)Contact us at 615-577-1704 or 1-866-403-5858 if you would like to be present for the exam(s) or have any questionsregarding the exam. For information about Well Child’s Privacy Practices, please visit www.wellchild.com. 2019 Well Child, Inc. This document may not be used, duplicated, or published without the express legal consent of Well Child, Inc.

Tired of filling out Well Child’s paper packetseach year?Let Well Child help complete yourpacket over the phone.Call (615) 577-1704 or (866) 403-5858.You can also complete the packetonline at www.wellchild.com (scanQR Code to left). Fill it out onlineonce, and each year you only haveto update your information. 2019 Well Child, Inc. This document may not be used, duplicated, or published without the express legal consent of Well Child, Inc.

EXAM CONSENTIt is very important that you complete every questionName of School Grade Section TeacherCHILD’S INFORMATIONLAST NAMEFIRSTM.I.ADDRESSSEX:RACE:CITYSTATEMain language at home:ZIPChild’s doctor or iteOtherNon- HispanicDate of BirthWell Child will bill your insurance carrier or managed care organization for the exam(s). Circle name of TennCare Provider:United Health Care Community Plan, TennCare Select, BlueCare, Amerigroup, Cover Kids, Other:CHILD’S SOCIAL SECURITY NUMBERTennCare Member ID #Tricare DOD Benefit #:Insurance Company: Policy #: Group#:Policy holder name: Date of Birth:*Vision Exams only accept the following insurance carriers: United Health Care(MarchVision), TennCare Select,BlueCare & CoverKids.RESPONSIBLE PARTY’S NAMELEGAL GUARDIAN’S INFORMATIONRELATIONSHIP TO CHILDHOME PHONE NUMBER WORK PHONE NUMBER CELL PHONE NUMBERBy checking here you consent to()( )( )receive notifications by text messageE-MAIL ADDRESS:Friend or relative whom we can contact in case of emergency and share medical information.Name Relationship Phone ( )LEGAL GUARDIAN CONSENT AND ACKNOWLEDGMENTI have been notified of Well Child’s privacy practices. I authorize Well Child to send screening results home with my child in a sealed envelope,to release information to my insurance carrier in order to process payment claims, and to receive payment of medical benefits for servicesrendered. For purposes of treatment and referral, I authorize release of medical information to the Health Department, the school system, child’sphysician/primary care provider, and/or optometrist. I give permission to the school district to release my child’s immunization (shot) record forreview by Well Child. This consent and authorization is effective until revoked by me. I agree to pay Well Child any coinsurance required by mychild’s health insurer. Notice of Privacy Practices is available at: www.wellchild.com or I may obtain a written copy by calling Well Child at (615)577-1704 or (866) 403-5858 toll free.I wish to receive a copy of Well Child’s Notice of Privacy Practices in the mail.If you want the Well Child Yearly exam for your child PLEASE SIGN below.SIGN HEREDate: Legal Guardian Signature:If you want the Eye Exam service for your child PLEASE SIGN below.SIGN HEREDate: Legal Guardian Signature:Pupil dilation is using eye drops to make the pupil larger to help the doctors examine the inner health. Dilation can include some sensitivity tolight and mild blurred vision for about 2 – 3 hours. To ensure my child’s eye health is normal:I authorize pupil dilationI will schedule pupil dilation at a later dateAllow your 3, 4, or 5 year old child to receive up to two (2) applications of fluoride varnish per year. The benefits of fluoride include strengtheningyour child's teeth and a 30-35% decrease in tooth decay. It is safe and easy to apply. Sometimes after the application the teeth will appearyellow. The varnish can be brushed off the next morning after it is applied and the teeth will be the same as before. Please check one below:I authorize fluoride treatmentI will schedule fluoride treatment at a later date 2019 Well Child, Inc. This document may not be used, duplicated, or published without the express legal consent of Well Child, Inc.

MEDICAL HISTORYChild’s Name: SSN:Answer Yes with a 1. Child’s Health History:Acne/Skin problemsADHD/ADDAnemiaAsthmaAutismArthritisHas your child had any of the following?Bladder problemsEpilepsyBronchitisHeadachesCancerHeart murmurDiabetes/SugarHigh blood pressureEar InfectionsHigh CholesterolEczemaHIVUNKNOWNNO TO ALLLiver troubleSickle Cell TraitMumpsSickle Cell DiseaseNavel HerniaSinus congestionPassed outThyroid problemsPE tubes in earsWeight changeSeizuresOther:Anemia Risk Assessment:Exposure to LeadPoor GrowthPicky EaterAges 3-5Strict Vegetarian DietPoor GrowthPicky EaterAges 6-10Ages 11-21Females after 1st period startsMales during peak growth spurtsWell Child does further lab testing for anemia and glucose (sugar) depending on age and child’s health history. Theselab tests are performed by a finger stick following the American Academy of Pediatrics guidelines.If you would NOT like these test, please sign here2. Asthma: How often does your child need to use the inhaler because of wheezing?Per WeekPer MonthPer YearNeverHas your child been in the hospital or emergency room for an asthma attack in the past 12 months?YesNoUnknown3. Developmental History:Did your child have delays in:NoneLearningWalkingTalkingWas your child born early?YesNoUnknownDid mother or child have difficulties during pregnancy or birth?YesNoUnknownUnknown4. Current Treatment: Please check below any service your child is currently receiving:Development (motor skills/learning)5. Immunizations (shots) up to date?Speech/languageYesNoUnknown6. Family History: Has anyone in your family had any of the following?AsthmaDiabetes/SugarHigh Blood Pressure7. Allergies:MedicinesVision (glasses or contacts)UNKNOWNMental hBee/Wasp StingNO TO ALLSickle CellNO ALLERGIESLatexCurrent Medicines: List over-the-counter and prescription medicine: 2019 Well Child, Inc. This document may not be used, duplicated, or published without the express legal consent of Well Child, Inc.OtherNO MEDICATIONS

MEDICAL HISTORY CONTINUEDChild’s Name:Answer Yes with a 8. Surgeries or Hospitalizations?YesNoUnknownIf Yes, explain and give dates.9. Social/Socioeconomic History: Number of Children at home?Does anyone smoke in the home?Does your child wear a seat belt?Does child have problems in school?YesYesYesNoNoNoAre you a single parent?A working smoke alarm?YesYesNoNoDeclined10. Exercise/Elimination:How many days a week does your child exercise more than 30 minutes?Child's bowel movement:NormalDiarrhea# of days/weekHard11. Child Eye Health History: Has your child had any of the following?GlaucomaRetinal DiseaseCataractsDry EyeEye painTired EyeEye infectionEye itchingDouble visionEye rednessEye injury: When Which eyeUNKNOWNRetinal DiseaseEye turn/Drooping lid13. Child Eye Exam: Is this your child’s first eye exam?Date of last exam:Does your child wear glasses?Yes14. Dental History:YESYESYESYESYESYESNO TO ALLBlurred visionLoss of vision/BlindnessStye or ChalazionFlashes/floaters in visionReading DifficultyGlared or light sensitivityEye turn/Drooping lidExcess watering and tearingAmblyopia/StrabismusFeels like something in the eyeEye surgery: When Which eye12. Family Eye History: Has anyone in your family had any of the following?GlaucomaCataracts0- 3 days4 days# of days/weekUNKNOWNNO TO ALLAmblyopia/StrabismusLoss of vision/BlindnessYesNoUnknownNo(FOR AGES 3, 4, AND 5 ONLY)NODoes your child have an allergy to colophony or pine nuts?NOHas your child ever seen a dentist? If yes, when and where?NODo you brush your child’s teeth? How many times per day?NODo you brush your child’s teeth with fluoride toothpaste?NODo you give your child tap water?NODoes your child use a bottle? 2019 Well Child, Inc. This document may not be used, duplicated, or published without the express legal consent of Well Child, Inc.UNKNOWN

RISK ASSESSMENT QUESTIONNAIREChild’s Name:Tuberculosis:Yes1Has your child been in close contact with a person with infectious tuberculosis?24Does your child have HIV infection or considered at risk for HIV Infection?Does your child have contact with any of the following: HIV infected homeless, nursing home,institutionalized individuals, illicit drug users, or migrant farm workers?Does your child have a poor immune system due to disease or treatment of disease?5Was your child born in Asia, Africa, or Latin America, a refugee, or an immigrant?6Does your child live in an established “high risk for tuberculosis” community or area?3Lead – Children 12 months through 5 years ONLY.789YesNoNoNot SureDoes your child live in or regularly visit a house/apartment built before 1950?Does your child live in or visit a house/apartment built before 1978 with recentongoing repairs?Does your child have a sibling or playmate that has, or did have lead poisoning?Your child may be referred to your primary care physician or to the Health Department if your answers aboveindicate testing is needed.PEDIATRIC SYMPTOM CHECKLIST 17 (PSC-17)Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child’sbehavior, emotions, or learning you can help your child get the best care possible by answering the following questions. Pleaseindicate which statement best describes your child.Never1Fidgety, unable to sit still2Feels sad, unhappy3Daydreams too much4Refuses to share5Does not understand other people’s feelings6Feels hopeless7Has trouble concentrating8Fights with other children9Is down on himself or herself10Blames others for his/her troubles11Seems to be having less fun12Does not listen to rules13Acts as if driven by a motor14Teases others15Worries a lot16Takes things that do not belong to him/herSometimesOften17Distracted easilyCOMMENTS: 2019 Well Child, Inc. This document may not be used, duplicated, or published without the express legal consent of Well Child, Inc.