of CHILUKt:N '"'..,.., , ,........ • - DEPARTMer.rr
COUNTY OF LOS ANGELES
MEDICAL EXAMINATION FORM - INSTRUCTIONS cAREGIVERS on the reverse side of this form.
Please refer to the CONSENT & MEDICAL REf.QRD P~OcedURES FOR FOSTEB.--(To be completed by CSW/Caregiver. Please print legibly.)
.
.
t be
d. ally examined within ten (10) days of initial placement, or sooner if medically
D lnfa~ts (0-36 months) or "High Ris~" c~ildre~;:su;ne
of the following conditio_
ns exists: a past or present significant _medi~al
reqwred or recommended . "High Risk incl~
disease· on medication ; and/or a social problem (e.g., language barrier) which might
problem or chronic illness; possible contagious
'
conceal an unmet medical need.
D
Child must have medical exam within thirty (30) days of initial placement.
D
Child needs annual/age-appropriate medical exam by _ _ _ __ _
CHILD 's NAME:
CAREGIVER:
CSW :
- - - - -- - --
-----
DOB:
- - - - - - - - -- -
------------
CASE #:
-----------
DATE PLACED : _ _ __
(Phone) _ _ _ _ __ (FFA) _ _ _ _ _ _ _ _ _ _ (Phone;L--- - - -
(File#) _ _ __ __ _ __
_
(Phone) _ _ _ _ _ _ (Fax) _ _ _ _ _ __
(Date)
Medical data entered into CWS/CMS by: (Name)
MEDICAL EXAMINATION FORM
(To be completed by Doctor.)
*PLEASE SEE PAGE 2 FOR DEVELOPMENTAL SCREENING DOCUMENTATION
PHYSICAL EXAMINATION
Doctor is a CHOP provider?
D Yes D No
Was child tested for lead poisoning?
D
D
D
Yes
D
No
Name of Doctor:
Date of Physical Examination:
D
D
Initial CHOP/CHOP-equivalent examination.
D
Annual/age-appropriate CHOP/CHOP-equivalent examination .
D
Other/Follow-up visit.
D
Doctor's own exam form or PM 160 attached .
If not attached, complete below.
Physical Exam results: Age:
Body Mass Index (BMI) Score:
(Yrs.):
(Mos.):
(Wks.)
Body Mass Index%:
Condition and treatment were explained to the caregiver
and child/youth (as age appropriate).
Youth may self administer his/her own medication with
adult supervision .
Youth is authorized to self administer his/her own
medication.
Height:
%
Weight:
%
(May be continued on additional pages in necessary. If so, provider must date and sign second page.)
(Treatment given; Medications Prescribed. Please attach copies of supporting documentation; test results, etc.)
If follow-up care indicated, specify:
Immunizations given :
(If appropriate, complete immunization Record)
Signature of Health Care Provider:
Address :
- - - (Date)
(Doctor, Nurse Practitioner, Physician 's Assi·-st_a_n...,.t)_ _ __
--;;::;---:--:---:-c,---~-
Phone:
(Sionature Stamp Reouired)
CONSENT (Caregiver is a Foster Parent, Relative, Group Home, or FFA)
DCFS 561(a) (Rev. 1/2017) MEDICAL EXAMINATION FORM
. Lea ve several forms w· th th
I
.
. ..
Make photocop of co
e caregiver when the child is 1111t1ally placed.
.
File the comple,d/ . mpleted/signed original and provide photocopy to caregiver.
signed original in the Psychological/Medical/Dental fold er.
l
COUNTY OF Los
AMIL y SERVICE!
DEPARTMENT OF CHILDREN AND F
ANGE LES
d ' al
Consent of the
.
.
.
havin the child undergo ~ny me IC ,
dental and rn parent or guardian (via the DCFS 179) or court authorization must be obtained prior to f th ~ate time and location of the ·t
1
1
exam , and in~: health scree nings and examinations. CSWs or Caregivers must inform the parents om if~he p~rent does not respond
th
th e exa
the Parent can t e parent of the opportunity to be present. It is not necessary to reschedule _
on the parent's phone. It rs
necessary to r no hatte nd - Notice may be provided orally, text, email, mail, in-person, or by leaving a message
esc edule the exam if:
?r
•
•
•
The Parent ob·
.
Th
Jects to the exam , even 1fthe parent previously gave consent
e Parent ne
·
The ,
ver signed the DCFS 179 providing consent
res no court order for the exam
MEDICAL RECORD
The HEAL TH
PROCEDURES FOR FOSTER CAREGIVERS
,
.
er
(CSW) will revf EDUCATION PASSPORT (HEP) BINDER accompanies each child at the time of placement. The Childr~n s Socia_lWor\ the
initial examina ew t~e. HEP BINDER with you at each visit. The Health and Education Passport must be taken to all medical visits, mclud, g
the ch ild' HE ~on visit. The health care provider must record all current medical services on the DCFS 561(a). Plea se add COrf!ple!ed forms to
shall b s
BINDER. If the child is removed from your care, the child's complete HEP BINDER, including the Immunization Record,
e returned to the CSW at the time of removal, as the HEP BINDER must accompany the child upon replacement.
lm~~d iately notify the child 's CSW (or Supervising CSW if the CSW is unavailable) when there is any change in the child's mental,
me •cal and/or dental health that required urgent medic~! care.
Please use th e Child Health and Disability Prevention (CHOP) Program for medical and dental examinations. Please refer to the following
CHOP
· d' ·
·
peno ,c,ty schedule. For more information on the CHOP program please refer to the CHOP brochure in the HEP BINDER.
HEALTH CARE EXAMINATIONS PERIODICITY SCHEDULE
Infants (0-36 months) or "High Risk" children must be medically examined within ten (1 O) days of initial placement, or sooner if medically
required or recommended . Foster children four (4) years of age and older who are not considered high risk, must have a medical examination
within 30 days of the initial placement. Children are also to have immunizations according to the current Recommended Childhood
Immunization Schedule.
Inform the CSW of all medical appointments as soon they have been made including the date, time and location.
Children must receive CHOP program or CHOP program equivalent medical examinations, at a minimum , as follows:
•
•
•
•
•
Children
Children
Children
Children
Children
under one ( 1) month need an examination
two (2) to six (6) months need an examination every two (2) months, for a total of three (3) exams
seven (7) to eighteen (18) months need quarterly (every 3 months) examinations, for a total of four (4) exams
nineteen (19) to thirty (30) months need one examination every six (6) months, for a total of two (2) examinations
three (3) to twenty-one (21) years need annual (yearly) examinations
*DEVELOPMENTAL SCREENING INFORMATION (to be completed by Health Care Provider)
D Yes
D
•
Developmental Screening Completed?:
•
If Yes, what type:
•
•
Developmental Screen Concerns?:
0No
Developmental Screen Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
DCFS 561(a) (R ev.
No
D Ages & Stages Questionnaire
0PEOS
0 Denver Developmental Screen
0 Other:. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
1/2017) MEDICAL EXAMINATION FORM
Lea ve several forms wilh the caregiver when the ch ild is initially placed .
Make photocopy ol comp leted/signed original and provide photocopy to car ·
File the completed/signed original in the Psyc hological/ Medica l/Dental lolde('ver.
Page 2 of 2