Well Child Exam-Middle Childhood: 6 - 10 Year
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WELL CHILD EXAM-MIDDLE CHILDHOOD: 6 – 10 Year
DATE
PATIENT NAME
DOB
SEX
PARENT NAME
Allergies
Current Medications
Prenatal/Family History
Weight
Percentile
Length
Percentile
BMI
Percentile
Temp.
Pulse
Resp.
BP
%
%
%
Interval History:
Anticipatory Guidance/Health Education
□ Y
□ N
Patient Unclothed
(Include injury/illness, visits to other health
(√ if discussed)
care providers, changes in family or home)
Review of
Physical
Safety
Systems
Exam
Systems
□ Discuss avoiding alcohol, tobacco, drugs
N
A
N
A
□ Monitor TV viewing & computer games
General
□
□
□
□
□ Booster seat/seat belt use in back seat
Appearance
□ Keep home and car smoke-free
Nutrition
□
□
□
□
Skin/nodes
□ Teach outdoor, bike, and water safety
□ Grains _______ servings per day
□ Use bike helmet/protective sporting gear
□
□
□
□
□ Fruit/Vegetables ______ servings per day
Head
□ Teach stranger and home safety
□ Whole Milk _____ servings per day
□ Gun safety
□
□
□
□
Eyes
□ Meat/Beans _______ servings per day
Nutrition/physical activity
□ City water □ Well water □ Bottled water
□
□
□
□
Ears
□ Limit sugar and high fat food/drinks
Elimination
□ Normal
□ Abnormal
□ Regular family meals
Exercise Assessment
□
□
□
□
Nose
□ Offer variety of healthy foods and include 5
Physical Activity: _______ minutes per day
servings of fruits & veggies every day
□
□
□
□
Oropharynx
□ Normal
□ Abnormal
Sleep
□ Limit TV, video, and computer games
Additional area for comments on page 2
□
□
□
□
□ Physical activity & adequate sleep
Gums/palate
Screening and Procedures:
Oral Health
□ Oral Health Risk Assessment (6 year olds)
□
□
□
□
Neck
□ Schedule dental appointment
Hearing
□ Discuss flossing, fluoride, sealants
□
□
□
□
Lungs
□ Screening audiometry (6 Year olds; 7 – 10
Child Development and Behavior
year olds if risk assessment positive)
□ Encourage independence
□
□
□
□
Heart/pulses
□ Parental observation/concerns
□ Answer questions about puberty simply
Vision
□
□
□
□
Abdomen
□ Consistently reinforce limits & family rules
□ Visual acuity
□ Praise child and encourage child to talk
□
□
□
□
_____R _____L _____Both
Genitalia
about feelings, school, and friends
□ Parental observation/concerns
□ Supervise child’s activities
□
□
□
□
Spine
Developmental Surveillance
□ Assign household tasks & responsibilities
□ Social-Emotional □ Communicative
□
□
□
□
Extremities/hips
Family Support and Relationships
□ Cognitive □ Physical Development
□ Listen/show interest in child’s activities
Psychosocial/Behavioral Assessment
□
□
□
□
Neurological
□ Spend family time together
□ Y □ N
□ Set reasonable but challenging goals
□ Normal Growth and Development
Screening for Abuse
□ Y □ N
□ Encourage positive interaction with
□ Tanner Stage ___________
siblings, teachers and friends
□ Abnormal Findings and Comments
Screen If Risk:
□ Offer constructive ways to handle family
If yes, see additional note area on next page
□ IPPD _________ (result)
conflict and anger; don’t allow violence
□ Hct or Hgb ______(result)
□ Know child’s friends and their families
Results of visit discussed with child/parent
□ Dyslipidemia ______(result) at 6, 8, 10 yrs
□ Be a positive role model for your child
□ Y □ N
If not previously tested:
□ Substance Abuse, Child Abuse, Domestic
□ Lead level ______ mcg/dl (for 6 year olds -
Violence Prevention, Depression
Plan
required for Medicaid)
□ Ensure safe, supervised after school care
□ History/Problem List/Meds Updated
Immunizations:
□ Referrals
Next Well Check: _______ years of age
□ Immunizations Reviewed, Given & Charted
□ Children Special Health Care Needs
If needed but not given, document rationale
Developmental Surveillance on Page 2
□ Transportation
□ IPV □ DTaP □ MMR
□ Influenza
Page 3 required for Foster Care Children
□ Other__________________________
□ Varicella or Chicken Pox Date: _________
Provider Signature:
□ Other _______________________________
□ MCIR checked/updated
□ Acetaminophen ____ mg. q. 4 hours
PAGE 1
Updated 4/2011
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