THS Forms

Medical Checkup

Child Health Clinical Record

These forms are available for providers to use as a documentation tool for all required checkup components. They should never be given out as a client questionnaire. The forms are recommended but not required for your use by Texas Health Steps.

How to Download Child Health Record Forms

Go to the Texas Health Steps online catalog and click on the Browse button. Under Main Menu, click on View Catalog Items, then Child Health Records located on the left navigational pane. Select the record for the appropriate age, then click on the yellow starburst to download a printable and fillable PDF.

How to Use Child Health Clinical Record Forms

Please review these instructions for using Child Health Record forms (PDF). The PDF forms include fillable fields (text fields, check boxes, etc.) so that you can complete the forms using Adobe Reader. Visit the File Viewing webpage for information on downloading Adobe Reader.

Developmental and Mental Health Screening

*Reused with permission from "Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit," American Academy of Pediatrics, June 23, 2010.

These documents are part of the American Academy of Pediatrics' "Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit," which is designed to provide primary care clinicians guidance to enhance the quality of mental health care for children and adolescents, whether in or through the medical home. The toolkit brings together more than 250 resources and tools on one quick reference CD-ROM and is available for purchase online.

TB Questionnaire

Hearing Screening Questionnaire

Laboratory Tests


ECI Referral Form

Texas Health Steps Provider Outreach Referral Form

The Texas Health Steps Provider Outreach Referral form should be used by all providers who submit a referral on behalf of a THSteps patient who needs assistance:

  • Scheduling a follow-up appointment.
  • Rescheduling a missed appointment.
  • Scheduling transportation to an appointment.
  • With other outreach services.

The following limitations and restrictions apply to the THSteps Provider Outreach Referral form:

  • Only one referral form can be used for up to two patients in a household; if there are more than two patients in the same household, an additional referral form must be used.
  • Referrals should not be submitted for patients who are 21 or older or are insured by the Children's Health Insurance Program.

The referral form is available in either Microsoft Word or PDF, and can be completed electronically or by hand or electronically and faxed using the coversheet included with the form. Download the instructions (PDF) for more information.

THSteps providers who have questions about the referral form or need information about the THSteps Provider Outreach Referral Service should contact the appropriate THSteps Provider Relations representative in their region (PDF).

Growth Charts

Additional Questionnaires, Forms and Tools