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Get Healthy Kids Epsdt Visit Forms

NEVADA HEALTHY KIDS EPSDT /WELL BABY/WELL CHILD Initial New Patient Screening Form CPT 99381-99385 Name Date DOB Age Sex Medicaid Parent/Guardian Name Provider NPI Patient s Medical History Birth Weight Birth Length Serious Injury/IllnessSurgeries Menarch/Sexual History if applicable Behavioral/Emotional History Family Medical History Check disease indicate family member with the problem Asthma/Allergies Heart Attack/Stroke P-parent G-grandparent.

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