Texas caregivers bring this form to every medical, dental, vision, hearing or behavioral health visit for a child in Department of Family and Protective Services (DFPS) conservatorship. It documents the 3-day medical exam after removal, Texas Health Steps checkups, dental visits and CANS assessments to meet residential child care licensing standards, contracts and Child Protective Services policy. The caregiver files a copy with the CPS caseworker.
The caregiver, such as a foster parent, relative or residential operation representative, completes Section I with the child's, caregiver's and caseworker's details and the reason for the visit. The health care provider completes Section II when possible or attaches medical records instead; otherwise the caregiver completes it and checks that the provider was unable to.
The person bringing the child completes this before the visit: the child's name, date of birth, DFPS Person Identification (PID) number and appointment date; the caregiver's name, phone, agency and address; and the CPS caseworker's name, phone and fax. A caregiver can be a foster parent, relative, non-relative or representative of a residential operation.
The caregiver checks why the child is being seen, and each box shows its deadline: 3-day medical exam, child with primary medical needs, initial or updated CANS assessment, initial or routine Texas Health Steps medical and dental checkups, other checkups, vision or hearing check, ER visit, specialty visit, or an illness, injury or accident follow-up described with the date and time of the incident. The checked reason tells CPS which requirement the visit meets.
The caregiver records whether the child takes any medications and lists each with dosage, what it is prescribed for and instructions, with room for caregiver comments. The DFPS staff member or caregiver then signs and dates Section I. Section II has its own medication table where the provider records discontinued, new or changed medications.
Enter the child's name, date of birth and appointment date, or check that the child refused the appointment. Record age, temperature, pulse, respirations, blood pressure, height, weight, head circumference and BMI with percentiles. Vision screening asks for each eye's 20/ value and glasses status, and hearing screening for results at 500 to 4000 Hz, with options for subjectively normal, not done, unable to comply, refused, or a full eye or audiology exam recommended.
Check the procedures and tests done at the visit: autism screen, hemoglobin, PPD TB screen, blood lead test, lead screen, developmental screen or other (list), or none. List the diagnoses from the visit, and mark whether it was a well child visit, a routine dental visit or other (list).
For each medication, give name, dosage, what it is prescribed for and instructions, and mark it discontinued, new or changed, or check no medication changes. Check each vaccine given, from DTaP, Tdap and MMR to HPV, influenza, PCV13 and PPSV23, or none administered. The form repeats that vaccines are not allowed at the 3-day exam except emergency tetanus or with direct consent from a biological parent.
Check any referrals: Early Childhood Intervention (ECI), speech, occupational or physical therapy, a specialist (give the type) or other, or none necessary. Under follow-up, state when and why the child should return, or mark none necessary, and add provider comments. Therapy referrals belong here even though the form itself is not required at the later therapy visits.
Sign and print your name, and add the clinic name, address, phone, fax and date signed. If a medical or dental provider did not complete Section II, the caregiver signs here instead and checks the statement that the health care provider was unable to complete the form.
Download the current version from the source each time; forms change without notice.
Medical, Dental, Vision, Hearing, or Behavioral Health Appointment
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Sources for this guide
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DFPS asks the provider to complete Section II when possible. The provider may instead attach medical records or other information in place of Section II. If the provider cannot complete it, the person who brought the child fills in Section II, signs, and checks the box stating the health care provider was unable to complete the form.
Generally no. The form states that children and youth may not receive vaccinations at the 3-Day Medical Exam unless an emergency requires a tetanus vaccination or the provider gets direct consent from the biological parent or parents. Vaccines given at later visits are recorded in the Section II vaccine checklist.
The initial Texas Health Steps medical checkup is due within 30 days of entering DFPS conservatorship. After that, checkups follow the periodicity schedule: shortly after newborn discharge, at 2 weeks, at 2, 4, 6, 9, 12, 15, 18, 24, 30 and 36 months, and then annually. The initial dental checkup is due within 60 days for children 6 months or older.
DFPS's instructions for the form point providers to the Health Passport, an electronic health information tool for children in foster care. Health care providers can open it through Superior Health Plan's secure provider portal. The form itself still travels with the caregiver to each visit.