3 - 5/6 - 11/adolescent Checkup Forms
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33 - 5 YEARS CHECKUP
Date:_________________
Name:____________________________________ Address:_______________________________________ Phone:_____________________
DOB:_______________ Sex:_____________ Age:__________
Parent/Guardian:____________________________________________
Physical Exam:
Temp:________ BP:________ HT:______ WT:______ BMI%:______ BMI VALUE:_____ Vision: pass/fail
Hearing: pass/fail
DIET: Well Balanced Yes/No
Calcium Intake: Yes/No
Vitamin Supplement: Yes/No
Variety of Foods: Yes/No
Adequate variety of foods: Yes/No
Adequate fl uid intake: Yes/No
Allergies:
NKDA:
√= Normal X= Abnormal
DESCRIPTION OR ABNORMAL (BY NUMBERS)
1. GENERAL
√
X
MEDICATIONS:
IMPRESSION:
2. SKIN
3. HEAD
NORMAL EXAM
Yes
No
4. EYES
5. ENT
6. NECK
7. THROAT
8. SPINE
PLAN:
9. LUNGS
10. HEART
FOLLOW UP
Yes
No
11. PULSES
12. ABDOMEN
13. GU
FOLLOW UP APPT. DATE:___________
14. EXTREMITIES
15. HIPS
16. NEURO
17. OTHER
Growth & Development Concerns:
School Readiness Concerns:
DEVELOPMENT: LEAVE BLANK = NOT ASKED
SOCIAL:
Hops, jumps, runs
Yes
No
Talks in paragraphs
Yes No
Primary caretaker/childcare
Copies circles
Yes
No
Knows 911
Yes No
Home occupants
Kicks a ball
Yes
No
Copies shapes
Yes No
Childcare/preschool
Pedals tricycle/bike
Yes
No
Knows address & phone number
Yes No
Immunocompromised
Yes
No
Knows fi rst name, gender & age
Yes
No
Draws 6 part person
Yes No
Pets
Yes
No
Balance on 1 foot
Yes
No
Name a friend
Yes No
Tobacco exposure
Yes
No
Removes clothes
Yes
No
Distinguishes fantasy & reality
Yes No
Firearms
Yes
No
Speaks in sentences
Yes
No
Plays well with other kids
Yes No
Varicella disease
Yes
No
Speech is intelligible to others
Yes
No
Peers/Sibling relationship
Yes No
Cholesterol risk
Yes
No
Toilet trained
Yes
No
Parent relationship
Yes No
Car seat/booster/seatbelt
Yes
No
Feeds self
Yes
No
Behavior issues
Yes No
Lead exposure
Yes
No
Brushes teeth
Yes
No
After school care
Yes No
TB exposure
Yes
No
Counts to ________
Yes
No
Extracurricular activities
Yes No
Adequate fl uoride
Yes
No
Developmental concerns
Yes
No
Other
Yes No
Dental exam
Yes
No
IMMUNIZATIONS
DUE TODAY:
DTaP
PCV
HepA
Polio
IMMUNIZATIONS UP TO DATE FOR AGE:
HepB
Rotavirus
Hib
Varicella
MMR
Infl uenza
MD Counseled (Discussed) Benefi ts & Risks of Vaccines
Meningococcal
H1N1
ANTICIPATORY GUIDANCE - HEALTH/SAFETY - PSYCHOSOCIAL
LABS:
Family meals
Praise, encourage, play
LEAD (IF AT RISK)
Feed self/basic table manners
Listen, respect, interest in activities
Nutritional counseling/encourage healthy snacks
Read stories regularly
Weight management addressed
Limit TV/computer/video games
UA: WNL
Physical Activity counseling/encourage exercise
Water safety/sunscreen
Physical Activity counseling/handout given
No playing with matches
Nutritional counseling/handout given
Smoke/CO detector
Hgb/Hct
__________
Naps/quiet time
Tuberculosis (TB) Risk Assessment
Individual attention
Lead Risk Assessment
See Lab Sheet (s)
Anticipatory handout given
Practitioner: _____________________________________________
Assistant:______________________________________
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