M23

MIECHV Baby’s Age 36 Months

Index Child

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Child ID #:

Name of Index Child:

Name of Index Parent:

Date data gathered: / / 20

1.	In the past 6 months, have you (parent) taken your (index) child to the emergency department for an injury?

Yes (If yes, please note the reason and date)	No

NOTE: ER visits for illness should not be noted

Reason:	Date: / / (month/day/year)

Reason:	Date: / / (month/day/year)

Reason:	Date: / / (month/day/year)

2.	Child’s current health Insurance status:

Not insured	State Children’s Insurance Program (SCHIP)

Private or employer’s Insurance	TRICARE or other military health care

OHP/Medicaid	Other insurance:

CAWEM/CAWEM Plus

3.	Has your child had the following well-child visit? 30 months:	Yes	No

4.	Where do you usually take your child for medical care?

Doctor’s/Nurse Practitioner’s Office

Hospital Emergency Room

Hospital Outpatient

Federally Qualified Health Center (FQHC)

Retail Store or Minute Clinic

Other:

5.	Does your child have a usual source of dental care?	Yes	No

6.	During a typical week, how many days do you (and/or a family member) read, tell stories and/or sing songs to your child?

0 – Not at all 1 2 3 4 5 6 7 – Every day