Well Child Visit Form - 3-4 Years
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1Well Child Visit: 3-4 Years
Name: ___________________________________
DOB: ________________ Date: __________________
Current Medications
Drug/Food Allergies
Accompanied By
Age
Ht.
Wt.
BMI
BMI %ile
B/P
Interpreter: Y / N
□M □F
Past Medical History
Interval History
Nutrition
Recent illness: □ Yes □No ___________
Sleep: □ NL_______________________
Appetite: □ NL _________________________
Elimination: □ NL __________________
Fruits/Vegetables: □ Yes □No _____________
________________________________
Child has dental home: □ Yes □No _____
Toilet training: □ Yes
□ In process
Milk/Calcium: □ Yes □No _________________
Vision Concerns: □ Yes □No __________
Behavior: □ NL ____________________
↓ sugary drinks: □ Yes □No _______________
Hearing Concerns: □ Yes □No
Play time >60 mins/day □ Yes □No ____
Snack habits: □ NL ______________________
Concerns: □ Yes □No ____________________
_________
Activities/sports: ___________________
F/u previous concern: □ None _________
Screen time <2hr/day □ Yes □No _______
_________________________________
Social / Family History
Growth-Development
Cognitive: □ NL ________________
Language: □ NL _______________
Lives at home with:__________________________________
Parent/ child interaction: □ Yes □No __________________
● identifies self as girl or boy. Names
● Clear speech. Sentences. Gives
Parents working outside home: □ Mother
□ Father
3-4 colors. Draws person with 3 parts
first & last name. Sings a song
Physical: □ NL _________________
Social: □ NL _________________
Child Care: □ Yes □No
Type: _______________
● Copies a circle/cross. Rides tricycle.
● Self-care skills (dresses self, etc.)
Family/ Work balance: □ Yes □No______________________
Walks up stairs alternating feet
Imaginary play. Listens to stories.
Recent family stressors: □ Yes □No____________________
Smoke exposure: □ Yes □ No _________________________
Preschool: □ Yes □No __________________________________________
Parental Concerns: ________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Physical Exam (checked □ = normal)
Abnormal Findings
□ General (Alert, NAD, socialization NL)
□ Heart (No murmurs, + femoral pulses)
□ Head (No deformities, symmetric)
□ Lungs (Clear breath sounds)
□ Eyes (PERRL, EOMI, + RR, cover test,
□ Abdomen (Soft, non-tender, no masses)
□ Skin (No rashes, no lesions)
lids NL, 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 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: _____________
no caries or white spots)
Assessment
Anticipatory Guidance
□ Well child
□ Behavior (Consistent discipline, encourage play with other children, encourage
□ Normal growth and development
fantasy play, emerging independence)
□ Safety (Bike helmet, playground and stranger safety, avoid second hand smoke)
□ Health Promotion (Family meals, nutrition, brush teeth, hand washing, daily
physical activity, family exercise activities, limit TV/screen time)
□ Development (Toilet training, playtime with other children, preschool,
language: read every day, listen and respond to child, sing songs together)
Plan
□ Education handout given
□ Immunizations (See immunization record)
□ Vision acuity: R___/___
L___/___ Both___/___
□ Lead screen (if not previously done)
□ Hearing screen: □ NL___________________
□ Dental referral
Next Appointment: _________________ Signature: ___________________________ Date: _____________
1014.QI.P.FO 10/14
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