Forms

Child Health Clinical Record Forms
Required Forms for the THSteps Checkup
Nutritional Assessment Forms

NOTE: The forms below are provided for your convenient use. The use of these forms is not required by Medicaid or the Texas Health Steps Program.

NOTE: The following forms must be used and completed when performing a THSteps checkup.

Pb-110 Abbreviated Parent Questionnaire (English and Spanish) and Guidelines
Pb-111 Detailed Parent Questionnaire (English and Spanish) and Guidelines
San Antonio State Chest Hospital Cervical Cancer Cytology Laboratory Form
Specimen Submission Form G-1A Instructions
Specimen Submission Form G-1A
Specimen Submission Form G-1B Instructions
Specimen Submission Form G-1B
Hearing Checklist for Parents
Tuberculosis Questionnaire (English)
Tuberculosis Questionnaire (Spanish)

NOTE: The forms below are provided for your convenient use. The use of these forms is not required by Medicaid or the Texas Health Steps Program.

Healthy Kids, Healthy Families Brochure (English) (852K) (viewing information)
Healthy Kids, Healthy Families Brochure (Spanish) (852K)(viewing information)
24-Hour Dietary Recall and Assessment for One Through Four Years (240K) (viewing information)
24-Hour Dietary Recall and Assessment for Five Through Nine Years (183K) (viewing information)
24-Hour Dietary Recall and Assessment for Ten Through Twenty Years (Nonpregnant) (193K) (viewing information)