Medical & Dental Forms

Periodic Medical and Dental exams, and Developmental Assessments, are required by the State of Michigan for all children in foster care. Well-Child Exams are more frequent for infants, and gradually taper off to once per year at age three. Yearly Dental Exams are required starting at age three, but any child should be seen by a dentist if you have any concerns about the child's oral health (more below). Developmental Assessments begin at age 6 months, and are generally due at the same ages Well-Child exams. See the schedule below for details, and for links to download the required forms for each visit.

Failure to include all required medical, developmental and dental forms in a foster child’s file could result in the State of Michigan considering the foster parents and/or agency as medically negligent!

TIPS FOR YOUR NEXT WELL-CHILD VISIT

BEFORE YOUR APPOINTMENT, make sure you have all the forms you need; they can be downloaded by clicking on the form name in the chart below. If a Developmental Assessment is also required for your child's age (see chart below), it should be completed by the child's foster parents and/or Case Manager BEFORE the Well-Child Exam. The completed Developmental Assessment form (ASQ, PSC or PSC-Y) should then be taken to the Well-Child Exam, along with the age-required Well-Child Exam (WCE) form, so the doctor can use it to complete their assessment (this will also save you time during your appointment). 

AT THE DOCTOR'S OFFICE, please ensure the doctor completes EVERY section of the Well-Child Exam form, and signs / dates each page. The doctor may encourage you to leave the form with them, to complete "later" and send to our office for you; however, we have a very low rate of success with receiving medical forms unless the foster parents leave with them in-hand. Also, doctors frequently skip over the developmental section of the Well-Child form (page 2 or 3), but this section is NOT optional at any age. If at all possible, you should leave the doctor's office with a completed Well Child Exam (WCE) form AND the completed Developmental Assessment form (ASQ or PSC) if one is required for your child's age.

SCHEDULE AND FORMS

Well-Child medical examinations, developmental assessments, and Dental visits are required at different age intervals, as shown in the schedule below. The required forms for each age can be downloaded by clicking on the form name in the table. Also, ASC forms can be completed online or downloaded from Easter Seals by clicking the large "ASC ONLINE" button below the table. (The Easter Seals website will ask for your child's birth date, and automatically give you the right form). If you have any questions about this schedule, or which forms are required at each age, your Case Manager will be happy to help! 

CHILD'S AGEWELL CHILD EXAM FORMDEVELOPMENTDENTAL*
1 Week WCE 1 Week (DHS-580) -- --
4 WeeksWCE 4 Weeks (DHS-579) -- --
2 MonthsWCE 2 Months (DHS-583) -- --
4 MonthsWCE 4 Months (DHS-581) -- --
6 MonthsWCE 6 Months (DHS-1641)ASQ 6M --
9 MonthsWCE 9 Months (DHS-1638) -- --
12 MonthsWCE 12 Months (DHS-1639)ASQ 12M --
15 MonthsWCE 15 Months (DHS-1640) -- --
18 MonthsWCE 18 Months (DHS-1631)ASQ 18M --
2 YearsWCE 2 Years (DHS-1632)ASQ 2Y --
30 MonthsWCE 30 Months (DHS-1633)ASQ 30M --
3 YearsWCE 3 Years (DHS-1634)ASQ 3YDHS-1664
4 YearsWCE 4 Years (DHS-1642)ASQ 4YDHS-1664
5 YearsWCE 5 Years (DHS-1635)ASQ 5YDHS-1664
6 to 10 YearsWCE 6-10 Years (DHS-381)PSCDHS-1664
11 to 14 YearsWCE 11-14 Years (DHS-1636)PSC or PSC-YDHS-1664
15 to 18 YearsWCE 15-18 Years (DHS-1637)PSC or PSC-YDHS-1664

* Yearly Dental exams are REQUIRED starting at three years of age, and must be documented on the "Youth Yearly Dental Record" form (DHS-1664). HOWEVER, children should be seen sooner (before age 3, or between annual exams) if any of the below circumstances apply. Documentation of such visits must be added to the child's foster care record (provided to the agency), and could either be made on a DHS-1664 form, or on a report from the Dental Practice. Reasons to seek dental care before age 3, or between annual exams:

  • If the child is referred for dental care by their pediatrician
  • If baby teeth have not erupted by age 6 months
  • If the child's teeth are discolored, broken, grossly misaligned or misshapen
  • If the child's gums are swollen, bleeding, discolored, and/or the child has persistent unexplained bad breath
  • If the child complains of persistent oral pain or discomfort not associated with normal teething
  • If the dentist recommends a return visit sooner than one year (i.e. 6 months)
  • If you have any concerns about the oral health of the child that has not been addressed by their pediatrician or dentist