Well Child Visit Form - 5-6 Years
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1Well Child Visit: 5-6 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
Toilet Trained: □ Yes □No
__________________________________
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
Lives at home with:_________________________________
Cognitive: □ NL ______________
Language: □ NL __________________
Tobacco smoke exposure: □ Yes □No
● Knows 4+ colors, counts to 10,
●Articulate, uses pronouns and
Parent/child/sibling interaction: □ NL ___________________
plays board/card games
tenses; tells simple stories
Cooperation/defiant behavior: □ NL __________________
School- Grade: _______ Special Education □ Yes □No
Physical: □ NL ______________
Social: □ NL ______________________
_____
● Balances on 1 foot, hops, skips;
●Engages in fantasy play. Able to listen
Performance □ NL _______ Peer interaction: □ NL ______
dresses self; mature pencil grasp
& attend; follows simple directions
Teacher concerns: □ None
__________________________
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, lips NL,
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, exercise daily, limit screen time,
□ Normal growth and development
bedtime routine)
□Safety (Playground & stranger danger, bike helmets, pedestrian, drowning)
□Learning (School readiness, meet teachers, show interest in school, read
with your child every day)
□Behavior (Praise, encourage, family rules, show interest in friends)
□Nutrition (Limit high fat/sugar foods, portion size, health snacks, vitamins)
Plan
□ Immunizations (See immunization record)
□ Lead screen (If not previously done)
□ Vision acuity: R___/___
L___/___ Both___/___
□ Hearing screen: □ NL___________________
□ Dental referral
Next Appointment: _________________ Signature: ___________________________ Date: _____________
0814.QI.P.FO 10/14
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