Reason for Medication Name Prescribing Physician – Length Prescribed Address Prescribing Physician – Yes No Is this a psychotropic medication? Yes No Specify: Has this medication been provided to the care provider? Name Medication Dosage / Frequency – Reason for Medication Name Prescribing Physician – Length Prescribed Address Prescribing Physician – Yes No Is this a psychotropic medication? Yes No Has this medication been provided to the Specify: care provider? F. Medical or Mental Health Appointments Yes No The child has currently scheduled medical or Specify: mental health appointments Date (mm/dd/yyyy) Time Name Provider – When is the child due for a periodic well child care exam? (Per DCF 56, children in out-of-home care must receive well child medical examinations in accordance with the schedule of the Wisconsin EPSDT/HealthCheck program): Birth 1 month – 2 months 4 months 6 months 9 months 12 months 15 months 18 months 24 months 30 months 36 months Annually from 3 6 years – Every other year from 6 21 years – G. Immunizations Yes No The child’s immunizations are up-to-date. Specify: Immunization Record Immunization Date(s) Administered V. ADDITIONAL INFORMATION
Reason for Medication Name – Prescribing Physician Length Prescribed Address – Prescribing Physician Yes No Is this a psychotropic medication? Yes No Has this medication been provided to the care provider? Specify: Name – Medication Dosage / Frequency Reason for Medication Name – Prescribing Physician Length Prescribed Address – Prescribing Physician Yes No Is this a psychotropic medication? Yes No Has this medication been provided to the care provider? Specify: F. Medical or Mental Health Appointments Yes No The child has currently scheduled medical or mental health appointments Specify: Date (mm/dd/yyyy) Time Name – Provider When is the child due for a periodic well child care exam? (Per DCF 56, children in out-of-home care must receive well child medical examinations in accordance with the schedule of the Wisconsin EPSDT/HealthCheck program): Birth – 1 month 2 months 4 months 6 months 9 months 12 months 15 months 18 months 24 months 30 months 36 months Annually from 3 – 6 years Every other year from 6 – 21 years G. Immunizations Yes No The child’s immunizations are up-to-date. Specify: Immunization Record Immunization Date(s) Administered V. ADDITIONAL INFORMATION
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