Texas Health Steps Provider Forms

THSteps Checkup Forms - Select this link to view a list below of links to forms whose completion is required during a THSteps medical checkup.

Case Management Forms

Texas Health Steps Missed Appointment Referral Form - Complete and fax Missed Appointment Referrals to 512-533-3867.

Texas Childhood Lead Poisoning Prevention Program - Physician Reference on Follow-up Testing and Case Management (Form #Pb-109)

Nutritional Screening Forms - Select this link to view a list below of links to forms provided for providers' convenient use when performing a nutritional screening during a THSteps medical checkup.

Nutrition and Exercise Brochures - Select this link to veiw brochures that promote healthy diet and exercise for families.

Child Health Clinical Record

• Child Health History (TDH Stock #TDH-ECH-1) (pdf, 417K, viewing information)
• Birth to One Month (TDH Stock #TDH-ECH-2) (pdf, 421.8K, viewing information)
• 2-6 Months (TDH Stock #TDH-ECH-3) (pdf, 420.4K, viewing information)
• 7-12 Months (TDH Stock #TDH-ECH-4) (pdf, 420.5K, viewing information)
• 13 Months-2 Years (TDH Stock #TDH-ECH-5) (pdf, 421.8K, viewing information)
• 3-5 Years (TDH Stock #TDH-ECH-6) (pdf, 421.4K, viewing information)
• 6-10 Years (TDH Stock #TDH-ECH-7 (pdf, 415.2K, viewing information)
• 11-21 Years (See TDH Adolescent Health Website)

THSteps Checkup Forms

Lead Exposure Screening Form

• Risk Assessment for Lead Exposure (English and Spanish) (pdf, 133K, viewing information)

THSteps Checkup Laboratory Specimen Forms

• Child Health Lab Supplies Order Form, Form #G399 (pdf, 24K, viewing information)
  This is a link to a sample form that must be completed to request THSteps laboratory supplies. Laboratory supplies are provided at no charge when used during collection of specimens for routine THSteps checkups. To order laboratory forms and other specimen supplies, contact the Texas Department of State Health Services Laboratory at 512/458-7661.
• THSteps Specimen Collection and Handling Guidance provided by the Texas Department of State Health Services.
• South Texas Laboratory Cervical Cancer Cytology Laboratory Form (pdf, 127K, viewing information)
• Newborn Screening (NBS) Specimen Collection Form, Form #NBS-3 (pdf, 412K)

A written request for NBS specimen collection forms and NBS supplies is required. To obtain an order form for written requests call 1-512-458-7661. To obtain NBS test results, call the NBS Automated Voice Response System (personal identification number is required) at 1-512-458-7300 or 1-888-963-7111, extension 7300. For more detailed information, visit the NBS web site. Note that the Newborn Screen is the only test performed by the DSHS Laboratory for Children's Health Insurance Program (CHIP) recipients.

Hearing Checklist Form

• Hearing Checklist for Parents (pdf, 469K viewing information)

Tuberculosis Questionnaire Forms

• Tuberculosis Questionnaire (English) (MS Word, 49K)
• Tuberculosis Questionnaire (Spanish) (MS Word, 39K)

Case Management Forms

• Looking for Ways to Better Serve Your Clients Provider Recruitment Form
  (pdf, 43K, viewing information)
• Finding Special Health-Related Services for a Client Referral Form
  (pdf, 32K, viewing information)

Nutritional Screening Forms

• Nutritional Screening - One Through Four Years (pdf, 240K, viewing information)
• Nutritional Screening - Five Through Nine Years (pdf, 183K, viewing information)
• Nutritional Screening - Ten Through Twenty Years (Nonpregnant) (pdf, 193K, viewing information)

Nutrition and Exercise Brochures

• Healthy Kids, Healthy Families Brochure (English) (pdf, 852K, viewing information)
• Healthy Kids, Healthy Families Brochure (Spanish) (pdf, 852K, viewing information)

The brochures above were made possible by a grant to the Centers for Disease Control and Prevention (CDC) Foundation from the MetLife Foundation. To print or order additional copies of these free brochures, or similar brochures for providers, teachers and principals, please visit the CDC Healthy Youth! web site or call (888) 231-6405.