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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : Appendix A. THSteps Forms : A.2 THSteps Medical Checkup Forms

The use of the child health clinical records is optional. These forms were developed to help providers document all components of the medical checkup. Unless required to be submitted to another program, one of the following forms of documentation must be included in the client’s medical record: The completed screening tools with results, the completed questions to the tools within a provider-created medical record, and the results of the completed screening tools. Providers may be asked to provide the screening tool used to complete the screening. Texas Health Steps (THSteps) requires the following forms: Tuberculosis (TB) Questionnaire and the Texas Department of State Health Services (DSHS) State Laboratory forms. These forms can be downloaded from the THSteps website at The Parent Hearing Checklist and Lead Risk Questionnaire are optional forms. Lead poisoning screening questionnaires can be downloaded from the Texas Childhood Lead Poisoning Prevention Program (TX CLPPP) website at
Links to growth charts may be found on the THSteps website at
ECHR‑4 Month
ECHR‑6 Month
ECHR‑9 Month
ECHR‑12 Month
ECHR‑15 Month
ECHR‑18 Month
ECHR‑24 Month
Providers should refer to sources such as Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (3rd edition), located at or the Guidelines for Adolescent Preventive Services (GAP) Implementation Materials located at For nutritional screening for all ages, refer to Bright Futures.

Texas Medicaid & Healthcare Partnership
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