Child and Teen Checkups (C&TC) Program
Information for Coordinators

C&TC Documentation Forms for Providers and Clinics

0-1 month visit (DHS-4813B)

2 month visit (DHS-4813C)

4 month visit (DHS-4813D)

6 month visit (DHS-4813E)

9 month visit (DHS-4813F)

12 month visit (DHS-4813G)

15 month visit (DHS-4813H)

18 month visit (DHS-4813I)

2 year visit (DHS-4813J)

3 year visit (DHS-4813K)

4 year visit (DHS-4813L)

5 year visit (DHS-4813M)

6-7 year visit (DHS-4813N)

8-10 year visit (DHS-4813O)

11-14 year visit (DHS-4813P)

15-17 year visit (DHS-4813Q)

18-20 year visit (DHS-4813R)

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