DCF-2147 Medical Questionnaire/Request for Information Revised January 2013 State of Connecticut Department of Children & Families

Medical Questionnaire/Request for Information

To:	HEALTH CARE PROVIDER	DATE
ADDRESS	FAX

From:	DCF INVESTIGATOR	TELEPHONE
AREA OFFICE	FAX

The Department of Children and Families has an open investigation concerning the child listed below. In accordance with our investigation policies, we are requesting information that would become part of the confidential file. Enclosed is a signed authorization to release information for your records. We ask that you take a moment to complete this form and return it to us within two weeks. Thank you for your anticipated assistance in this matter.

Family or Custodial Parent's Name:
Child/Youth:	DOB:
Date of Last Physical:	HT: WT: BMI:
How long has the child been a patient in your practice? years
Has child been seen elsewhere for medical care? If so, where?	NAME OF PROVIDER:
Is the patient up to date with immunizations and well child visits?	YES NO	IF NO, WHAT IS NEEDED?
Has child had lead level checked?	YES NO	IF YES, DATE:	LEVEL:
Are there any identified medical or dental problems?	YES NO	IF YES, PLEASE EXPLAIN:
Are there any developmental, behavioral, or mental health concerns?	YES NO	IF YES, PLEASE EXPLAIN CONCERN AND ANY SPECIALIST REFERRALS MADE:
If the patient is less than three (3) years of age would this patient benefit from a referral of Birth to Three Services?	YES NO	If YES, was a referral made to Birth to Three? YES NO Check here if patient already involved with Birth to Three

Is the child presently on any medication?	YES NO	IF YES, PLEASE LIST MEDICATION AND WHAT IT IS PRESCRIBED FOR:
List any specialist referrals made and dates:	NAME OF SPECIALIST:	DATE OF REFERRAL:
Any missed appointments/ pattern of missed appointments or other concerns you would like to discuss with the DCF investigator?

Health Care Provider's Signature:	Date:

Need to speak with Social Worker	BEST DAYS AND TIMES TO CONTACT:
Days:
Times:
Telephone:

Please attach a copy of:	Immunization records
Last physical exam
Fax to:
Fax #

PLEASE RETURN WITHIN TWO WEEKS