Birth History:
Click Birth History in the Health & Well-Being section.
Type in a response for Birth weight (in pounds) or select ‘Don’t Know’ if appropriate.
Select Vaginal or C-Section for Delivery method or select ‘Don’t Know’ if appropriate.
Select At term or Early for when the Baby was born or select ‘Don’t Know’ if appropriate. If ‘Early’ is selected, type in a response for ‘Indicate at how many weeks gestation if the baby was born early. Otherwise leave blank. Numeric input only’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘Did the baby have any problems right after birth’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘Was there any illness or problem with the mom’s pregnancy’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘During the pregnancy did the mother smoke’ or select ‘Don’t Know’ if appropriate. If Yes, type in a response for ‘what did the mother smoke’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘During the pregnancy did the mother drink alcohol’ or select ‘Don’t Know’ if appropriate. If Yes, type in a response for ‘when during the pregnancy did she drink’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘During the pregnancy did the mother use drugs/medicines’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘Did the baby go home with mother from the hospital’, or select ‘Don’t Know’ if appropriate.
Click Save.
Health Behaviors:
Click Health Behaviors in the Health & Well-Being section.
Select a response from the Never – Always scale for ‘How often can you/your child depend on having an adult to talk to’.
Select a response from the Never – Always scale for ‘If a problem or emergency arises, how often can you/your child depend on an adult to turn to for help and support’.
Select Yes or No for ‘… seen any non-violent crime in your/their neighborhood, such as someone selling drugs or stealing’.
Select Yes or No for ‘… seen any violent crimes taking place in your/their neighborhood, such as someone being beaten up’.
Select Yes or No for ‘… known someone other than yourself/themselves who was a victim of a violent crime in your/their neighborhood’.
Select Yes or No for ‘… been a victim of a violent crime in your/their neighborhood’.
Select Yes or No for ‘… been bullied at school (including cyberbullying) or in your/their neighborhood’.
Select Yes or No for ‘… experienced on-line bullying or threats (cyber-bullying)’.
10. Click Save.
Caregiver:
Click Caregiver in the Health & Well-Being section.
Select Yes or No for ‘Do you/Does your child have a caregiver that comes into the home, because of a health care problem, to provide you with assistance?’
Select Relative, Friend or Agency for ‘Is caregiver a relative, friend or from an agency?’
Type in a response for Caregiver/Agency Name.
Type in a number for Caregiver/Agency phone number.
Type in a response for Caregiver/Agency Specialty.
Select Per Day or Per Week for ‘ How many hours per day/week does caregiver come into your home?’. Then, type in a response.
Type in a response for ‘What items does your caregiver help with?’
Select Yes or No for ‘Do you/Does your child need more help than you are receiving?’ If Yes, type in an explanation.
Click Save.
ADL/IADL:
Click ADL / IADL in the Health & Well-Being section.
Select a response from the Independent – Cannot Do scale for Bathing.
Select Yes or No in the Receiving Help column for Bathing.
Select a response from the Independent – Cannot Do scale for Dressing.
Select Yes or No in the Receiving Help column for Dressing.
Select a response from the Independent – Cannot Do scale for Grooming.
Select Yes or No in the Receiving Help column for Grooming.
Select a response from the Independent – Cannot Do scale for Mouth care.
Select Yes or No in the Receiving Help column for Mouth care.
Select a response from the Independent – Cannot Do scale for Toileting.
Select Yes or No in the Receiving Help column for Toileting.
Select a response from the Independent – Cannot Do scale for Transferring bed/chair.
Select Yes or No in the Receiving Help column for Transferring bed/chair.
Select a response from the Independent – Cannot Do scale for Walking.
Select Yes or No in the Receiving Help column for Walking.
Select a response from the Independent – Cannot Do scale for Climbing stairs.
Select Yes or No in the Receiving Help column for Climbing stairs.
Select a response from the Independent – Cannot Do scale for Eating.
Select Yes or No in the Receiving Help column for Eating.
Select a response from the Independent – Cannot Do scale for Shopping.
Select Yes or No in the Receiving Help column for Shopping.
Select a response from the Independent – Cannot Do scale for Cooking.
Select Yes or No in the Receiving Help column for Cooking.
Click Save.
Sleep:
Click Sleep in the Health & Well-Being section.
Type in a response for ‘On average how many hours of sleep do you get in a 24 hour period’.
Select Yes or No for ‘Do you feel your sleep is restful?’
Employment:
Click Employment in the Health & Well-Being section.
Select a response from the ‘Employed – Full time’ – ‘Not in labor force’ scale. Select ‘Prefer not to answer’ if appropriate. If Not Employed, select a response(s) for question 1a. Select all that apply. If Employed, type in a response for question 1b.
Click Save.
Development:
Click Development in the Health & Well-Being section.
Select Yes or No for ‘Are you concerned about your/your child's physical development’. If Yes, type in an explanation.
Select Yes or No for ‘Are you concerned about your/your child's mental or emotional development’. If Yes, type in an explanation.
Select Yes or No for ‘Are you/Is your child having problems with behavior in school?’ If Yes, type in an explanation.
Select Yes or No for ‘Have you/Has your child failed or repeated a grade?’ If Yes, type in an explanation.
Select Yes or No for ‘Are you/Is your child having academic problems in school?’ If Yes, type in an explanation.
Select Yes or No for ‘Have you/Has your child failed or repeated a grade?’ If Yes, type in an explanation.
Select Yes or No for ‘Are you/Is your child in special resource classes/special education?’ If Yes, type in an explanation.
Click Save.
DME:
Click D.M.E. in the Health & Well-Being section.
Select a response from the Have – Don’t Need scale for any of the listed medical equipment (questions 1-23).
a. Click the teal, column-heading buttons in order to select the same response for questions 1-23. The select-all functionality can be used as a starting point if nearly all the answers will be the same.
Select Yes or No for ‘Do you have other adaptive equipment that is not listed above?’ If Yes, type in an description.
Select Yes or No for ‘Do you want other adaptive equipment that is not listed above?’ If Yes, type in an description.
Click Save.
Legal:
Click Legal in the Health & Well-Being section.
Select Yes or No for ‘Do you/Does your child have an advance directive and/or living will?’. Select ‘Don’t Know’ if appropriate. If Yes, select Yes or No for ‘Do you/Does your child have a copy of your advance directive and/or living will to put in your record?’
Select Yes or No for ‘Do you/Does your child have a psychiatric advance directive?’. Select ‘Don’t Know’ if appropriate. If Yes, select Yes or No for ‘Do you/Does your child have a copy of your advance directive and/or living will to put in your record?’
Select Yes or No for ‘Have you/Has your child given Power of Attorney (POA) to someone?’. If Yes, type in a response for whom. If Yes, select Yes or No for ‘Do you/Does your child have a copy of your POA to put in your record?’
Safety/Injuries:
Click Safety/Injuries in the Health & Well-Being section.
Select Yes or No for ‘Have you/Has your child ever been physically, sexually, or emotionally abused’.
Select Yes or No for ‘Have you/Has your child ever been in foster care, group home(s), or been homeless’.
Select Yes or No for ‘Have you/Has your child ever been in jail or in a detention center.
Select a response from the None – More than 1-time scale for ‘Been out of your/their parent's or caregiver's control so that the police needed to get involved’.
Select a response from the None – More than 1-time scale for ‘Purposefully damaged or destroyed (other than fire) property that did not belong to you/them’.
Select a response from the None – More than 1-time scale for ‘Taken something from a store without paying for it’.
Select a response from the None – More than 1-time scale for ‘Hit someone or been in a physical fight’.
Select a response from the None – More than 1-time scale for ‘Gotten a ticket or citation for a traffic violation (driving too fast, driving through a red light, etc.)’.
Select Yes or No for ‘Do you/Does your child have a gun/firearm in the home’. If Yes, select Yes or No for ‘If yes, is it unloaded and locked up’.
Future Plans:
Click Future Plans in the Health & Well-Being section.
Type in a response for ‘What are your/your child's future plans for additional schooling, having a family, and career goals?’
Allergies:
Click Allergies in the Clinical Summary section.
Select Yes or No for Medication allergies. If Yes, type in a response for ‘what are they?’
Select Yes or No for Food allergies.
a. If Yes, type in a response for ‘what are they?’
Select Yes or No for Environmental allergies (hay fever, dust, etc.).
a. If Yes, type in a response for ‘what are they?’
Type in a Pharmacy Name.
a. If a Pharmacy Name is provided, type in the Pharmacy Location.
b. If a Pharmacy Name is provided, type in the Pharmacy Phone Number.
Click the +Add button to enter the current medication information.
a. Type the name of the Medication.
b. Type the Dose.
c. Type in a response for ‘How often do you take them?’
d. Pick a date from the calendar-picker for medication Start Date.
e. Type in a response for ‘What are they for?’
f. To add another medication, repeat step #6.
g. To remove a medication, click the Remove button next to that entry.
Click the +Add button to enter the previous medication information.
a. Only list atypical anti-psychotics from the following: Risperdal (Risperidone), Seroquel (Quetiapine), Geodon (Ziprasidone), Zyprexa (Olanzapine), Invega (Paliperidone), Saphiris (Asenipine), Clozaril (Clozapine), Abilify (Aripiprazole), Latuda (Lurasidone), Vraylar (Cariprazine), Rexulti (brexpiprazole).
b. Type the name of the Medication.
c. Type the Dose.
d. Type in a response for ‘How often do you take them?’
e. Pick a date from the calendar-picker for medication Start Date.
f. Pick a date from the calendar-picker for medication End Date.
g. Type in a response for ‘What are they for?’
h. To add another previous medication, repeat step #7.
i. To remove a medication, click the Remove button next to that entry.
Click Yes or No for ‘Now or in the past 6 months, have you taken any prescribed medications for emotional or behavioral symptoms?’
a. If Yes, Select Yes or No for ‘Have the medications helped you feel better?’
i. If Yes, type in a response for ‘In what ways have they helped?’
b. If Yes, select Yes or No for ‘In the past 6 months have you had any bad side effects from these medications?’
i. If Yes, type in a response for ‘What were the bad side effects?’
Click the +Add button to enter the over-the-counter medication information.
a. Type the name of the Medication, herb, vitamin or supplement.
b. Type the Dose.
c. Type in a response for ‘How often do you take them?’
d. Pick a date from the calendar-picker for medication Start Date.
e. Type in a response for ‘What are they for?’
f. To add another over-the-counter medication, repeat step #9.
g. To remove an over-the-counter medication, click the Remove button next to that entry.
10. Select a response from the ‘Do not have to take medicine’ – ‘Seldom take as prescribed’ for ‘Do you have trouble taking medications as prescribed?’
a. If taking medication, select Yes or No for ‘Do you want help with this?’
11. Click the +Add button to enter other treatments (counselling, psychotherapy, OT, PT, chiropractor, acupuncture, traditional healing, other).
a. Type in a response for other treatments.
b. To add another treatment, repeat step #11.
c. To remove a treatment, click the Remove button next to that entry.
12. Click Save.
1.12 Health History
Click Health History in the Clinical Summary section.
For questions 1-76, click Past, Present, or both for ‘Condition/Behavior - Do you have or have you ever had:’.
a. If you select Present or both Past and Present for questions 1-76, select a response from Yes – No for ‘how much are you bothered by this condition/behavior?’
b. If you select Present, Past, or both Past and Present for questions 1-76, select Yes or No for ‘Would you like to talk about this with your provider?’
Select Yes or No for ‘Problems with teeth’.
Select Yes or No for ‘Problems with gums.
Select Yes or No for ‘Difficulty chewing’.
Select Yes or No for ‘Difficulty swallowing.
Select Yes or No for ‘Appetite change last six months’.
Select Yes or No for ‘Weight loss’.
Select Yes or No for ‘Weight gain’
10. Select Yes or No for ‘Penis discharge’.
11. Select Yes or No for ‘Sore on penis’.
12. Select Yes or No for Erectile dysfunction.
13. Select Yes or No for ‘Testicular lump’.
14. Select Yes or No for Vasectomy.
15. Select Yes or No for PSA.
a. If Yes, select a date for the PSA from the calendar-picker.
16. Select Yes or No for ‘Prostate problems’.
17. Select Yes or No for ‘Prostate exam’.
a. If Yes, select a date for the exam from the calendar-picker.
18. Click Save.
1.13 E.R. Visits
Click E.R. Visits in the Clinical Summary section.
Click the teal +Add button to enter an E.R. Visit.
a. Select a Month/Year from the calendar-picker.
b. Type in a Reason for the E.R. Visit.
c. To add another E.R. Visit, repeat step #2.
d. To remove an E.R. Visit, click Remove next to that entry.
Click Save.
1.14 Surgeries
Click Surgeries in the Clinical Summary section.
Click the teal +Add button to enter a Surgery.
a. Select a Month/Year from the calendar-picker.
b. Type in a Reason for the Surgery.
c. To add another Surgery, repeat step #2.
d. To remove a Surgery, click Remove next to that entry.
Click Save.
1.15 Substance Abuse Treatments
Click Substance Abuse Treatments in the Clinical Summary section.
Click the teal +Add button to enter a Substance Abuse Treatment.
a. Select a Month/Year from the calendar-picker.
b. Type in a Reason for the Substance Abuse Treatment.
c. To add another Substance Abuse Treatment, repeat step #2.
d. To remove a Substance Abuse Treatment, click Remove next to that entry.
Click Save.
1.16 Immunizations
Click Immunizations in the Clinical Summary section.
Select Yes or No for ‘Up to date?’. Select ‘Don’t know/Not sure’ or ‘Refused’ if appropriate.
Select Yes or No for ‘During the past 12 months have you had either a flu shot or a flu vaccine that was sprayed into your nose?’. Select ‘Don’t know/Not sure’ or ‘Refused’ if appropriate.
Select Yes or No for ‘A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime, and is different from the flu shot. Have you ever had a pneumonia shot?’. Select ‘Don’t know/Not sure’ or ‘Refused’ if appropriate.
Select Yes or No for Chicken Pox. Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
Select Yes or No for DTaP (diptheria, tetanus, acellular pertussis; 5 doses at 2, 4 6, 15 -18 mo & 4-6 yrs; <7 yrs). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
Select Yes or No for Influenza (annual dose beginning at 6 mos). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
Select Yes or No for Hepatitis A (2 doses; and 18-23 mos). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
Select Yes or No for Hepatitis B (3 doses, birth, 1 to 2 mo & 6 to 18 mos). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
10. Select Yes or No for Hib (Haemophilus influenzae type b; 4 doses at 2, 4, 12 or 15 mos). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
11. Select Yes or No for HPV (Human Papilloma Virus; ages 11 to 26 females; ages 11 to 21 males). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
12. Select Yes or No for IPV (Inactivated poliovirus; 4 doses ; 2, 4, 6 -18 mos & 4-6 yrs; <18 yrs). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
13. Select Yes or No for MMR (measles, mumps rubella; 2 doses 12-15 mos & 4-6 yrs). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
14. Select Yes or No for Meningococcal (2 doses; 11-12 yrs and booster 16-18 yrs). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
15. Select Yes or No for PCV13 (Pneumococcal conjugate; 4 doses at 2, 4, 6, 12 or 15 mos). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
16. Select Yes or No for Shingles. Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
17. Select Yes or No for Td/Tdap (Tetanus, diphtheria, pertussis; 11 to 12 yrs; 10 yr boosters). Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.
18. Click Save.
1.17 Hospitalizations
Click Hospitalizations in the Clinical Summary section.
Click the teal +Add button to enter a Medical/Psychiatric Hospitalization
a. Select a Month/Year from the calendar-picker.
b. Type in a Reason for the Hospitalization.
c. To add another Hospitalization, repeat step #2.
d. To remove a Hospitalization, click Remove next to that entry.
Click Save.
1.18 Health Concerns
Click Health Concerns in the Clinical Summary section.
Select Yes or No for ‘Accident or injury prevention’.
Select Yes or No for ‘Ear, eye or mouth care’.
Select Yes or No for ‘Exercise and nutrition’.
Select Yes or No for ‘Health screening tests’.
Select Yes or No for ‘Money, housing case management’.
Select Yes or No for ‘Living will, end-of-life issues’.
Select Yes or No for ‘Long term care needs’.
Select Yes or No for ‘Family or personal problems’.
10. Select Yes or No for ‘Depression or other mental concerns’.
11. Select Yes or No for ‘Preventing cancer’.
12. Select Yes or No for ‘Preventing heart disease’.
13. Select Yes or No for ‘Preventing heart disease’.
14. Select Yes or No for Other.