Wisconsin's ForwardHealth HealthCheck program, its version of EPSDT, publishes twelve age-specific clinic visit templates, F-01068A through F-01068L, running from the 3 to 4 week visit to the teenager visit. Each records history, feeding or diet, a part-by-part exam, developmental observations and parent interaction, with printed anticipatory guidance for that age. Completion is voluntary, and the form stays in the chart.
The HealthCheck screener, usually the pediatric or primary care clinician, completes the exam and observations and signs with the date. Families complete separate questionnaires, such as the family history and individual health history forms.
Download the current version from the source each time; forms change without notice.
HealthCheck Age Specific Documentation (General Pediatric Clinic visit forms)
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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No. The forms state that completion is voluntary. They are templates the HealthCheck screener can use to document an age-specific well-child visit, and the completed form is kept in the child's medical record rather than sent to ForwardHealth.
The clinician visit templates, F-01068A to F-01068L, are in English. Several companion questionnaires completed by families are available in Spanish, including F-01063 Family History and F-01062 Adolescent Review, and F-01002 Individual Health History is also offered in Hmong. The Confidential Health Survey has a Spanish version, F-01068MS.