Texas Health Steps Provider Forms


Texas Health Steps Medical Checkup Forms

Child Health Clinical Record Forms

Texas Health Steps Child Health Clinical Record forms have been updated to reflect July 1, 2018, Texas Health Steps policy changes.

Developmental and Mental Health Screening

Ages and Stages

PEDS

M-CHAT™ or M-CHAT-R/F™  (Modified Checklist for Autism in Toddlers, Revised with Follow-Up)

Edinburgh Postnatal Depression Scale (EPDS)

Postpartum Depression Screening Scale (PPDS)

Patient Health Questionnaire (PHQ-9)

Pediatric Symptom Checklist (PSC-17)

Pediatric Symptom Checklist (PSC-35)

Pediatric Symptom Checklist for Youth (Y-PSC)

Patient Health Questionnaire Modified for Adolescents (PHQ-A [depression screen]) (Under CLICK HERE at left, select Depression, then select PHQ-A [Adolescent Depression])

Car, Relax, Alone, Forget, Family, and Trouble Checklist (CRAFFT)

Patient Health Questionnaire for Adolescents (PHQ-A [anxiety, eating problems, mood problems and substance abuse screen])*

Patient Health Questionnaire for Adolescents (PHQ-A) Manual and Scoring Instructions*

*Reused with permission from the American Academy of Pediatrics, Addressing Mental Health Concerns in Primary Care:  A clinician’s Toolkit, American Academy of Pediatrics, June 23, 2010.

These documents are part of the American Academy of Pediatrics’ Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit, which is designed to provide primary care clinicians guidance to enhance the quality of mental health care children and adolescents receive, whether in the medical home itself or through the medical home. Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit brings together more than 250 resources and tools on one quick reference CD-ROM. Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit is available for purchase here:  https://shop.aap.org/addressing-mental-health-concerns-in-primary-care-a-clinicians-toolkit/.

TB Questionnaire

Texas Health Steps Tuberculosis Questionnaire   PDF [100KB]   Word DOC [84KB]

Laboratory Tests

Lead Risk Questionnaire Form Pb-110

Texas Health Steps Specimen Collection and Handling Guidance 

Lab Order Forms

Referrals

ECI Referral Form (developed by ECI and the Texas Pediatric Society)

Texas Health Steps Provider Outreach Referral Form

Growth Charts

Child’s age Recommended Growth Chart
Birth to 2 years of age World Health Organization (WHO)
2 years of age and older Centers for Disease Control and Prevention (CDC)


Additional Questionnaires, Forms, and Tools

Bright Futures

 

Last updated July 16, 2018