CCNC Provider Tools Site Inventory Updated Oct 2014 1Pediatric Tool List Link Description

ADHD: Med Info - Types, Dosage, Side Effects

(AAP/NICHQ)

http://www.communitycarenc.org/media/tool-

resource-files/adhd-med-info-types-dosage-side-

effects-aapnichq.pdfNICHQ/ AAP - 2-page medication management

information

ADHD: Parent Initial (Vanderbilt- AAP/NICHQ) -

English

http://www.ncfahp.org/data/sites/1/media/imag

es/pdf/03VanAssesScaleParent%20Infor.pdf Parent initial

ADHD: Parent Initial (Vanderbilt- AAP/NICHQ) -

Spanish

http://gtownpeds.com/uploads/DSC_Sistema_NI

CHQ_P.F.0506.pdf Parent initial -Spanish

ADHD: Parent Follow-up (Vanderbilt Follow-up

AAP/NICHQ) - English

http://www.ncfahp.org/data/sites/1/media/imag

es/pdf/05VanFollowUp%20Parent%20Infor.pdf Parent follow up

ADHD: Parent Follow-up (Vanderbilt AAP/NICHQ) -

Spanish

http://gtownpeds.com/uploads/DSC_NICHQ_Seg

uimento_Evaluacion_P.F.0506.pdf Parent follow up- Spanish

ADHD: Teacher Initial (Vanderbilt - AAP/NICHQ) -

English

http://www.ncfahp.org/data/sites/1/media/imag

es/pdf/04VanAssesScaleTeachInfor.pdf Teacher initial

ADHD: Teacher Follow-up (Vanderbilt-

AAP/NICHQ) - English

http://www.ncfahp.org/data/sites/1/media/imag

es/pdf/06VanAssessFollowUpTeachInfor.pdf Teacher follow up

ADHD: Vanderbilt Scoring Instructions

(AAP/NICHQ)

http://www.ncfahp.org/data/sites/1/media/imag

es/pdf/07Scoring%20Instructions.pdf Scoring Vanderbilt

Antipsychotics in Children - A+ KIDS: Keeping It

Documented for Safety http://www.documentforsafety.org/pub/

Online registry designed to increase the safety

and efficacy of antipsychotics prescribed to NC

Medicaid children through baseline and follow-

up monitoring. (CCNC and NC Medicaid)

Antipsychotics: Questions to Ask Prescriber

http://www.ncfahp.org/Data/Sites/1/icare-

resources/foster-care/questionstoaskprescriber-

final.pdf

Antipsychotics Pediatric "Cheat Sheet" (NCFAHP)

http://www.ncfahp.org/Data/Sites/1/f3-

fostercare-med-cheat-sheetantipsychotic.pdf

ADHD

Antipsychotics

1

CCNC Provider Tools Site Inventory Updated Oct 2014 2

Pediatric Behavioral Health – Guide to

Psychopharmacology for Pediatricians

http://web.jhu.edu/pedmentalhealth/Psychopha

rmacolog%20use.htmlfrom the Johns Hopkins Center for Mental

Health Services in Pediatric Primary Care

Anxiety - Screen for Childhood Anxiety Related

Disorders (SCARED), Parent Version, Ages <8

http://psychiatry.pitt.edu/sites/default/files/Doc

uments/assessments/SCARED%20Parent.pdf

Screen for separation anxiety, social phobia,

school phobia and physical symptoms of

anxiety.

Pediatric Anxiety - Screen for Childhood Anxiety

Related Disorders (SCARED), Child Version, ages

8-11

http://www.psychiatry.pitt.edu/sites/default/file

s/Documents/assessments/SCARED%20Child.pdf

Screen for separation anxiety, social phobia,

school phobia and physical symptoms of

anxiety.

Anaphyllaxis Action Plan (American Acad of

Allergy, Asthma & Immunology) - English

http://www.aaaai.org/Aaaai/media/MediaLibrary

/PDF%20Documents/Libraries/Anaphylaxis-

Emergency-Action-Plan.pdf To go with patient to school, camp, or institution

Anaphyllaxis Action Plan (American Acad of

Allergy, Asthma & Immunology) - Spanish

http://www.aaaai.org/Aaaai/media/MediaLibrary

/PDF%20Documents/Spanish/Anaphylaxis-

Emergency-Action-Plan-Spanish.pdf To go with patient to school, camp, or institution

Asthma 1a - Initial Visit Instructions and Key Steps

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/asthma1a-initial-visit-instructions-

key-steps.pdf

Asthma 1b: Follow Up Visit Instructions and Key

Steps (CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/asthma1b-follow-visit-instructions-

key-steps-.pdf

Asthma 2 - Facts About Asthma (CCNC) English &

Spanish

http://www.communitycarenc.org/media/tool-

resource-files/asthma-2-facts-about-asthma-ccnc-

english-spanish.pdf

Asthma 3 - Asthma Triggers (CCNC) English &

Spanish

http://www.communitycarenc.org/media/tool-

resource-files/asthma-3-asthma-triggers-ccnc-

english-spanish.pdf

Asthma 4 - Medication Photos Posters (CCNC)

English & Spanish

http://www.communitycarenc.org/media/tool-

resource-files/asthma-4-medication-photos-

posters-ccnc-english-sp.pdf

Asthma 5 - Medication Photos Poster for Young

Children (CCNC) English & Spanish

http://www.communitycarenc.org/media/tool-

resource-files/asthma-5-medication-photos-

poster-young-children-c.pdf

Asthma 6 - Nebulizer Poster for Young Children

(CCNC) English & Spanish

http://www.communitycarenc.org/media/tool-

resource-files/asthma-6-nebulizer-poster-young-

children-ccnc-engl.pdf

Anxiety

Asthma/Allergy

2

CCNC Provider Tools Site Inventory Updated Oct 2014 3

Asthma Action Plan (CCNC/NCAP/AANC) Print and

Write On - English

http://www.communitycarenc.org/media/tool-

resource-files/nc-asthma-action-plan-nc-dhhsdpi-

english.pdf

Asthma Action Plan (CCNC/NCAP/AANC) Print and

Write On - Spanish

http://www.communitycarenc.org/media/tool-

resource-files/nc-asthma-action-plan-nc-dhhsdpi-

spanish.pdf

Asthma Action Plan: How to Complete Written Plan

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/asthma-action-plan-how-complete-

written-plan.pdf

Asthma Action Plan: Instructions for Filling In

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/asthma-action-plan.pdf

Enter personal best or expected peak flow at top

left and the other peak flows auto-fill. Enter

"green zone" meds and "yellow zone" autofills so

you can just increase frequency if appropriate.

Asthma Action Plan: Type into PDF, Save and Print

(CCNC) - English

http://www.communitycarenc.org/media/tool-

resource-files/asthma-action-plan-one-page-

version.pdfJust the 1 page form, no instructions attached.

Use IE, Firefox or Chrome browsers.

Asthma Control Test age 4-11 - English & Spanish

http://www.communitycarenc.org/media/tool-

resource-files/childhood-asthma-control-test-

ages-4-11-english-sp.pdf

Asthma Control Test age 12-Adult (QualityMetrics) -

English & Spanish

http://www.communitycarenc.org/media/tool-

resource-files/asthma-control-test-ages-12-and-

over-english-spani.pdf

Constipation (Ped) Treatment and Referral

Guidelines (CCNC/CHACC)

http://communitycarenc.com/media/files/pediat

ric-constipation-guidelines.pdf

Constipation (Ped) - Guide for Parents and

Families (CCNC/CHACC)

http://www.communitycarenc.org/media/files/ki

ds-and-constipation-guide-parents-and-

families.pdf

Constipation (Ped) - Home Cleanout Guide for

Parents and Families (CCNC/CHACC)

http://www.communitycarenc.org/media/files/h

ome-clean-out-guide-parents-and-families.pdfDirections for home, Provider must check off

appropriate dose

Diabetes: A1c Stoplight Graphic (CCNC) - English

http://www.communitycarenc.org/media/tool-

resource-files/diabetes-a1c-stoplight-graphic-

ccnc-english.pdf Discussion tool about A1c

Constipation

Diabetes

3

CCNC Provider Tools Site Inventory Updated Oct 2014 4

Diabetes: A1c Stoplight Graphic (CCNC) - Spanish

http://www.communitycarenc.org/media/tool-

resource-files/diabetes-a1c-stoplight-graphic-

ccnc-spanish.pdf Discussion tool about A1c

Diabetes: Adjusting Insulin Doses (Endocrine

Society) http://www.accurateinsulin.org/for-doctors/

Diabetes: Self-Management Goal Sheet 

http://www.ccwjc.com/Forms/Diabetes/Patient

%20Education/Diabetes%20Self%20Care%20Goal

s.pdf

Foster Care Comprehensive Visit Summary

http://www.ncfahp.org/Data/Sites/1/icare-

resources/foster-care/foster-care-comprehensive-

assessment-report-streamlined-jan-2013.pdf From NCFAHP

Foster Care One-Pager (CCNC) 

http://www.communitycarenc.org/media/tool-

resource-files/foster-care-one-pager.pdfFoster Care Resources for Care (NC Foundation

for Advanced Health Programs) http://www.ncfahp.org/foster-care.aspx

Pediatric Functional Abd Pain - Differential

Diagnoses- Conditions and Criteria

(CCNC/CHACC)

http://www.communitycarenc.org/media/files/p

ed-ab-pain-guidelines-rome-iii.pdf

Developed in a collaboration of pediatric

gastroenterologists from the Departments of

Pediatrics at Carolinas Health Care, Duke

University, ECU, UNC, and Wake Forest

University and PCPs from across NC

Pediatric Functional Abd Pain - Primary Care

Evaluation and Management (CCNC/CHACC)

http://www.communitycarenc.org/media/files/p

ed-ab-pain-guidelines.pdf

Pediatric Functional Abd Pain - Tips for Decision

Making in Primary Care (CCNC/CHACC)

http://www.communitycarenc.org/media/files/p

ed-ab-pain-provid.pdf

Pediatric Functional Abd Pain - Management

Algorithm (CCNC/CHACC)

http://www.communitycarenc.org/media/files/p

ed-ab-pain-guidelines-algorithm.pdf

Pediatric Chronic Abd Pain - Symptom history

checklist (CCNC/CHACC)

http://www.communitycarenc.org/media/files/c

hronic-abdominal-pain-checklist.pdf

Pediatric Functional Abd Pain - Parent information

(NASPGHAN) - English

http://www.communitycarenc.org/media/files/f

unctional-ab-pain-child-eng.pdf

Pediatric Functional Abd Pain- Parent information

(NASPGHAN) - Spanish

http://www.communitycarenc.org/media/files/f

unctional-ab-pain-child-span.pdf

Functional Abdominal Pain

Foster Care

4

CCNC Provider Tools Site Inventory Updated Oct 2014 5

GERD (Ped) - Treatment and Referral Guidelines

(CCNC/CHACC)

http://communitycarenc.com/media/files/pediat

ric-gastroesophageal-reflux-guidelines.pdf

Developed in a collaboration of pediatric

gastroenterologists from the Departments of

Pediatrics at Carolinas Health Care, Duke

University, ECU, UNC, and Wake Forest

University and PCPs from across NC

GERD (Ped) Parents Take-home Guide to GERD

(CCNC/CHACC) - English

http://www.communitycarenc.org/media/files/ki

ds-and-constipation-guide-parents-and-

families.pdf

GERD (Ped) Parents Take-home Guide to GERD

(CCNC/CHACC) - Spanish

http://www.communitycarenc.org/media/tool-

resource-files/gerd-parent-guide-spanish-

chacc.pdf

Fever: Ibup,Tylenol Dosing Chart by Weight

(Piedmont Health Services) - English & Spanish

http://www.communitycarenc.org/media/tool-

resource-files/fever-ibup-tylenol-dosing-chart-

weight-piedmont-he.pdf

Need to circle the weight-appropriate dose for

the patient at MD visit and use teach-back to

make sure understood.

HIV: Fact Sheets, Resources, FAQs

(aidsinfonet.org) - English, Spanish and Nepali http://aidsinfonet.org/printing-downloading

Lots of info from New Mexico AIDS Education

and Training Center funded by FDA and

National Library of Medicine.

STDs Current Treatment Guidelines (CDC) http://www.cdc.gov/std/treatment/default.htmRegularly updated website with current

guidelines for treatment of STDs.

Obesity - Color-Coded BMI Chart (Boys) 

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BMIChartBoys.pdf

Obesity - Color-Coded BMI Chart (Girls)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BMIChartGirls.pdf

Obesity: BMI Percentile Coding and Billing (CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/obesity-bmi-percentile-coding-and-

billing-ccnc.pdf

Weight Loss: Children (EatSmartMoveMore NC) -

English & Spanish

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/PediatricObesityTools.htmlPediatric obesity prevention and treatment

algorithms - physician tools for management

Weight Loss: Find a Local Program (NC Alliance

for Healthy Communities) 

http://www.ncahc.org/weight-management-

registry-north-carolina.htmlHelps you to find weight management programs

for your patients by zip code or county.

Obesity

Gastroesophageal Reflux/GERD

Infectious Disease

5

CCNC Provider Tools Site Inventory Updated Oct 2014 6

Weight Loss: Prescription 5-3-2-1

(EatSmartMoveMore NC) - English

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/PrescripPadBW.pdf

Prescription for 5 servings fruit/veg, 3

meals/day, 2 hours or less screen-time, 1 hour

or more of activity.

Weight Loss: Prescription 5-3-2-1

(EatSmartMoveMore NC) - Spanish

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/PrescripPadSpBW.pdf

Prescription for 5 servings fruit/veg, 3

meals/day, 2 hours or less screen-time, 1 hour

or more of activity.

Sickle Cell Care Guidelines Oriented by Problem

(CDC/Grady Health System)

http://scinfo.org/problem-oriented-clinical-

guidelines/

Guidelines for treating over 40 syndromes

common in SC patients, developed with US

DHHS funds and in use at Grady SC Center

Sickle Cell Care: Few BASIC Primary Care

Guidelines (CDC/NHLBI)

http://www.cdc.gov/NCBDDD/sicklecell/recomm

endations.html

Few basic evidence based pearls that should be

known by all providers treating patients with

Sickle Cell

Speech & Language RED FLAGS for Referral

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/speech-and-language-red-flags-

referral-ccnc.pdf

Speech Language Pathology Primer (CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/speech-language-pathology-primer-

ccnc.pdf

Adolescent Substance Abuse Screening - CRAFFT

- Spanish

http://www.ceasar-

boston.org/CRAFFT/pdf/CRAFFT_Spanish.pdfFrom Center for Adolescent Substance Abuse

Research (CeASAR)

Adolescent Substance Abuse Screening - CRAFFT

- English

http://www.ceasar-

boston.org/CRAFFT/pdf/CRAFFT_English.pdfFrom Center for Adolescent Substance Abuse

Research (CeASAR)

Alcoholism: Find AA Meeting/Chapter by Zip Code

(Alcoholics Anonymous) (English & Spanish

Meetings)

http://www.aa.org/pages/en_US/find-aa-

resources

Find local chapter by zip code. Call local chapter

for schedule of local meetings and other

information. Meetings in Spanish are available in

most parts of NC.

Tobacco Cessation: 800-QUITNOW One Page

Flier (NC DHHS) - Spanish

http://www.quitlinenc.com/docs/patient-

resources/quitlinenc-fact-sheet---

spanish.pdf?sfvrsn=6 One page 1800QUITNOW flier in Spanish

Tobacco Cessation: Resources for your Practice

(NC DHHS Quitline)

http://www.quitlinenc.com/health-

professionals/practice-resources/resources-for-

your-practice Posters, fliers, chart of NRT, etc

Tobacco Cessation

Sickle Cell Disease

Substance/Alcohol

Speech & Language

6

CCNC Provider Tools Site Inventory Updated Oct 2014 7

Tobacco Cessation: Quitline Fax Referral Form

(NC DHHS) - English

http://www.communitycarenc.org/media/tool-

resource-files/tobacco-cessation-quitline-fax-

referral-form-nc-dh.pdfFax referral form asking Quitline to call the

patient.

Tobacco Cessation: 800-QUITNOW One Page

Flier (NC DHHS) - English

http://www.quitlinenc.com/docs/patient-

resources/quitlinenc-fact-sheet.pdf?sfvrsn=6 One page flier with 1800-QUITNOW info.

ABCD (Assuring Better Child health and

Development) - Screening Overview

http://www.communitycarenc.org/media/tool-

resource-files/abcd-and-screening-chart.pdfABCD- Assuring Better Child health and

Development - Screening overview

Anticipatory Guidance and Well Visit Forms (Bright

Futures)

http://brightfutures.aap.org/tool_and_resource_

kit.html

Dental - Varnishing and Oral Health (CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/pediatrics-oral-health.pdf

Hearing - Early Hearing Loss Detection and

Intervention (CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/early-hearing-detection-and-

intervention-goals.pdf

Hearing - Hearing Assessments Age 0-5 years

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/hearing-assessments.pdf Hearing Assessments

Hearing - Newborn Hearing Screening: What it is

and What to do (CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/newborn-hearing-screening.pdf Newborn Hearing Screening

Immunizations for 0-6 yr (CDC) - English & Spanish

http://www.cdc.gov/vaccines/schedules/easy-to-

read/child.htmlEasy to read schedule-- better for lower literacy

populations than prior versions.

Newborn Screening - NC State Lab of Public Health

http://slphreporting.ncpublichealth.com/lims/Cli

nicalLims/Login.aspx

Pediatrics: RSV Prophyllaxis-Synagis-Medicaid

http://www.documentforsafety.org/pub/resourc

es?context=synagisPolicy and forms for obtaining RSV prophyllaxis

for at-risk patients.

Postpartum Depression: Edinburg Screening

Questionnaire - English

http://www.communitycarenc.org/media/tool-

resource-files/post-partum-depression-edinburg-

screening-english.pdf

0-12 Months

Well Care

7

CCNC Provider Tools Site Inventory Updated Oct 2014 8

Postpartum Depression: Edinburg Screening

Questionnaire - Spanish

http://www.communitycarenc.org/media/tool-

resource-files/post-partum-depression-edinburg-

spanish.pdf

Postpartum/ Maternal Depression - What to Do

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/ccnc-pediatrics-maternal-

depression-screening.pdf

Preventive Health - Recommendations for Pediatric

Preventive Health

http://www.ncfahp.org/Data/sites/1/media/ima

ges/pdf/CHIP-

RecommendationsPedsHealthCare.pdf

Well Child/Health Check Billing Guide (NC

Medicaid)

http://www.ncdhhs.gov/DMA/healthcheck/HC-

Billing_Guide_2013.pdf

ABCD (Assuring Better Child health and

Development) - Screening Overview

http://www.communitycarenc.org/media/tool-

resource-files/abcd-and-screening-chart.pdf

ABCD Positive Screenings and How to Refer

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/ccnc-pediatrics-abcd-referrals.pdf

ABCD Referral to CDSA - Age 0-3

http://www.communitycarenc.org/media/tool-

resource-files/abcd-referral-cdsa-age-0-3.pdf

ABCD Referral/Notification to DPI - Age 3-5

http://www.communitycarenc.org/media/tool-

resource-files/abcd-referralnotification-dpi-age-3-

5.pdf

ABCD Standard CDSA/DPI Feedback Form

http://www.communitycarenc.org/media/tool-

resource-files/abcd-standard-cdsadpi-feedback-

form.pdf

Anticipatory Guidance and Well Visit Forms (Bright

Futures)

http://brightfutures.aap.org/tool_and_resource_

kit.html

Autism – M-CHAT - English

http://www2.gsu.edu/~psydlr/Diana_L._Robins,_

Ph.D._files/M-CHAT.pdf

Autism - M-CHAT - Spanish

http://www2.gsu.edu/~psydlr/Diana_L._Robins,_

Ph.D._files/Spanish_M-CHATrev.pdf

1-5 Years

8

CCNC Provider Tools Site Inventory Updated Oct 2014 9

Autism - M-CHAT with follow up questions-25 pgs -

English

http://www2.gsu.edu/~psydlr/M-

CHAT/Official_M-CHAT_Website_files/M-CHAT-

R_F.pdf

Modified Checklist for Autism in Toddlers is a

free (for clinical and research purposes)

screening tool for autism. This tool links to a

page offering the M-CHAT screening tool in

English and 40+ other languages. The scoring

and instructions appear as if they would take

more than the "2 minutes." -- Link revised March

2014 HB

Autism - M-CHAT (website, many languages

available)

http://www.mchatscreen.com/Official_M-

CHAT_Website.html

Autism - Referral and Screening One-Pager

http://www.communitycarenc.org/media/tool-

resource-files/ccnc-pediatrics-autism-

screening.pdf

Blood Pressure Table (Boys)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BPTableBoys.pdf

Blood Pressure Table – (Girls)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BPTableGirls.pdf

Dental - Varnishing and Oral Health (CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/pediatrics-oral-health.pdf

Hearing - Hearing Assessments Age 0-5 years

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/hearing-assessments.pdf Hearing Assessments

Kindergarten Physical (Approved by NC DPI and

DHHS) - English

http://www.ncdhhs.gov/dph/wch/doc/aboutus/

KHA_1-11.pdf Fill out then print or vice versa

Kindergarten Physical (Approved by NC DPI and

DHHS) - Spanish

http://www.ncdhhs.gov/dph/wch/doc/aboutus/S

panish_KHA1-11.pdf Fill out then print or vice versa

Lead Exposure & Poisoning in Young Children

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/lead-exposure-poisoning-young-

children-ccnc.pdf

Obesity - Color-Coded BMI Chart (Boys) 

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BMIChartBoys.pdf

Obesity - Color-Coded BMI Chart (Girls)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BMIChartGirls.pdf

9

CCNC Provider Tools Site Inventory Updated Oct 2014 10

Speech & Language RED FLAGS for Referral

(CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/speech-and-language-red-flags-

referral-ccnc.pdf

Speech Language Pathology Primer (CCNC)

http://www.communitycarenc.org/media/tool-

resource-files/speech-language-pathology-primer-

ccnc.pdf

Well Child/Health Check Billing Guide (NC

Medicaid)

http://www.ncdhhs.gov/DMA/healthcheck/HC-

Billing_Guide_2013.pdf

ABCD (Assuring Better Child health and

Development) - Screening Overview

http://www.communitycarenc.org/media/tool-

resource-files/abcd-and-screening-chart.pdf

Blood Pressure Table (Boys)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BPTableBoys.pdf

Blood Pressure Table – (Girls)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BPTableGirls.pdf

Obesity - Color-Coded BMI Chart (Boys) 

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BMIChartBoys.pdf

Obesity - Color-Coded BMI Chart (Girls)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BMIChartGirls.pdf

Screening - Pediatric Symptom Checklist (parent of

age 5-16) - English

http://www.massgeneral.org/psychiatry/assets/P

SC-35.pdf

Screening - Pediatric Symptom Checklist (parent of

age 5-16) - Spanish

http://www.massgeneral.org/psychiatry/assets/P

SC_Spanish_1.pdf

Screening - Pediatric Symptom Checklist Scoring

Instructions

http://www.massgeneral.org/psychiatry/services

/psc_scoring.aspx

Well Child/Health Check Billing Guide (NC

Medicaid)

http://www.ncdhhs.gov/DMA/healthcheck/HC-

Billing_Guide_2013.pdf

ABCD (Assuring Better Child health and

Development) - Screening Overview

http://www.communitycarenc.org/media/tool-

resource-files/abcd-and-screening-chart.pdf

11-21 Years

6-10 Years

10

CCNC Provider Tools Site Inventory Updated Oct 2014 11

Blood Pressure Table (Boys)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BPTableBoys.pdf

Blood Pressure Table – (Girls)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BPTableGirls.pdf

Depression - PHQ-9 Depression Screen - English

http://www.phqscreeners.com/pdfs/02_PHQ-

9/English.pdf

Depression - PHQ-9 Depression Screen - Spanish

http://www.phqscreeners.com/pdfs/02_PHQ-

9/PHQ9_Spanish%20for%20the%20USA.pdf

Depression - PHQ-9 Depression Screen, Scoring

Instructions

http://brightfutures.aap.org/pdfs/Other%203/PH

Q-9%20Instructions%20for%20Use.pdf

Obesity - Color-Coded BMI Chart (Boys) 

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BMIChartBoys.pdf

Obesity - Color-Coded BMI Chart (Girls)

http://www.eatsmartmovemorenc.com/Pediatri

cObesityTools/Texts/BMIChartGirls.pdf

Screening - Guidelines for Adolescent Preventive

Services (GAPS), ages 11-14 - English

http://www.capefearpediatrics.com/pdf/522781-

younger%20adolescent%20english.pdf

Screening - Guidelines for Adolescent Preventive

Services (GAPS), ages 11-14 - Spanish

http://www.capefearpediatrics.com/pdf/522777-

younger%20adolescent%20spanish.pdf

Screening - Guidelines for Adolescent Preventive

Services (GAPS), ages 15-21 - English

http://www.capefearpediatrics.com/pdf/522778-

older%20adolescent%20english.pdf

Screening - Guidelines for Adolescent Preventive

Services (GAPS), ages 15-21 - Spanish

http://www.capefearpediatrics.com/pdf/522779-

older%20adolescent%20spanish.pdf

Screening - Guidelines for Adolescent Preventive

Services (GAPS), Parent/Guardian - English

http://www.uvpediatrics.com/Docs/GAPSParent

eng.pdf

Screening - Guidelines for Adolescent Preventive

Services (GAPS), Parent/ Guardian - Spanish

http://www.capefearpediatrics.com/pdf/GAPS%

20-%20Parent%20Sp.pdf

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CCNC Provider Tools Site Inventory Updated Oct 2014 12

Screening – Pediatric Symptom Checklist (Youth

Self-Report, age 11-18+) - English

http://www.massgeneral.org/psychiatry/assets/P

SCY-35_English.PDF

Screening – Pediatric Symptom Checklist (Youth

Self-Report, age 11-18+) - Spanish

http://www.massgeneral.org/psychiatry/assets/P

SC_Y_Youth_Self_Report_Spanish.pdf

Sports Pre-Participation Physical Exam Form

(AAP/AAFP/ACSM)

http://www.aafp.org/dam/AAFP/documents/pati

ent_care/fitness/ppephysicalexamform2010.pdf

Well Child/Health Check Billing Guide (NC

Medicaid)

http://www.ncdhhs.gov/DMA/healthcheck/HC-

Billing_Guide_2013.pdf

12