Well Child Visit Form - 7-10 Years
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1Well Child Visit: 7-10 Years
Name: ___________________________________
DOB: ________________ Date: __________________
Current Medications
Drug/ Food Allergies
Accompanied By
Age
Ht.
Wt.
BMI
BMI %ile
BP
Interpreter: Y / N
□M
□F
Past Medical History
Interval History
Nutrition
Recent illness/injury: □ Yes □No _________
Appetite: □ NL_____________________
Sleep: □ NL__________________________
Fruits/Vegetables: □ Yes □No ________
Elimination: □ NL _____________________
____________________________________
Pt has a dental home:□ Yes □No _________
Milk/Calcium: □ Yes □No ___________
Behavior: □ NL ______________________
Vision Concerns: □ Yes □No _____________
↓ sugary drinks: □ Yes □No _________
Play time >60 mins/day □ Yes □No _______
Hearing Concerns: □ Yes □No ____________
Snack habits: □ NL ________________
Activities/sports: ____________________
F/u previous concern: □ None ____________
Concerns: □ Yes □No _____________
Screen time <2hr/day □ Yes □No ________
Social / Family History
Growth-Development
Special Education: □ Yes □No ___________
Lives at home with:________________________________
School- Grade: ______
Performance: □ NL _________
Peer interaction: □ NL ________
Tobacco smoke exposure: □ Yes □No
Behavior: □ NL ____________
Homework: □ NL _____________
Parent/child interaction: □ NL _______________________
Teacher concerns: □ None _________________________________
Sibling interaction: □ NL ___________________________
After-school activities: □ Yes □No ______________________________
Cooperation: □ NL _______________________________
Hobbies: ____________________
Oppositional behavior: □ NL ________________________
Has friends: □ Yes □No _____________________________
Parental Concerns: ________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Physical Exam (checked □ = normal)
Abnormal Findings
□ General (Alert, NAD, socialization NL)
□ Heart (No murmurs)
□ Head (No deformities, symmetric)
□ Lungs (Clear breath sounds)
□ Eyes (PERRL, EOMI, + RR, lids NL,
□ Abdomen (Soft, non-tender, no masses)
□ Skin (No rashes, no lesions)
conjunctivae/sclera clear)
□ Ears (Canals clear, TMs normal, orients
□ Neuro (Tone, symmetry, strength & gait NL)
□ Extremities (Full ROM, strength/tone NL)
to sounds, voice)
□ Nose (Mucosa NL, patent)
□ Genitalia
□ Mouth/Throat (MMM, palate intact, lips &
Male (Penis NL: circ/uncir, no adhesions)
tongue NL, no oral lesions, no erythema)
Female (Labia/clitoris NL, no discharge)
□ Teeth (Gums NL, dentition NL, no staining,
Tanner Stage: ____________
caries or white spots)
Assessment
Anticipatory Guidance
□ Well child
□ Healthy Habits (Brush teeth 2x/day, dental visits 2x/year, hand washing,
□ Normal growth and development
exercise daily, sunscreen, limit screen time, bedtime routine)
□ Safety (Know child’s friends, bullying, monitor computer use, helmets and
sports pads, guns, seat belts)
□ Learning (Meet teachers, show interest in school, help with homework)
□ Behavior (Praise & encourage, family rules, show interest in friends)
□ Nutrition (Family meals, limit high fat/sugar foods, portion size, vitamins)
□ Development (Puberty & sexual development, encourage independence)
Plan
□ Immunizations (See immunization record)
□ Vision acuity: R___/___
L___/___ Both___/___
□ Hearing screen: □ NL___________________
□ Dental referral
Next Appointment: _________________ Signature: ___________________________ Date: _____________
1014.QI.P.FO 10/14
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