Well Child Visit Form - 30 Months
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1Well Child Visit: 30 Months
Name: ___________________________________
DOB: ________________ Date: __________________
Current Medications
Drug/Food Allergies
Accompanied By
Age
Ht.
Wt.
BMI
BMI %ile
Temp.
Interpreter: Y / N
□M
□F
Past Medical History
Interval History
Nutrition
Recent illness: □ Yes □No
Sleep: □ NL_________________________
□ Milk: __________ # oz/day :___________
□ bedtime routine
Fruits: □Yes □No ______________________
______________
Elimination: □ NL _____________________
___________________________________
Vegetables: □Yes □No__________________
Child has dental home: □ Yes □No _______
Toilet training: □ Yes
□ In process
Meats: □ Yes □No ____
Vitamins:□Yes □No
F/u previous concern: □ None ___________
Behavior: □ NL _______________________
Healthy snacks: □ Yes □No Juice: □Yes □No
Play time >60 mins/day □ Yes □No _______
___________________________________
Concerns:____________________________
Screen time <2hr/day □ Yes □No ________
Social / Family History
Growth-Development
□ Structured developmental screening: □NL
Tool_________________
Lives at home with:_______________________________
Parent/ child interaction: □ Yes □No _________________
Cognitive: □ NL ________________
Language: □ NL ________________
Tobacco smoke exposure: □ Yes □No_______________
● Answers “where” questions.
● Uses 3-4 word phrases. Others can
Parents working outside home: □ Mother
□ Father
combines nouns & verbs “mommy go”
understand 50% of child’s language
Child Care: □ Yes □No
Type: _____________________
Physical: □ NL _________________
Social: □ NL __________________
Family/ Work balance: □ Yes □No___________________
● Throws ball overhand. Copies a
● Imaginary play. Plays with other
Recent family stressors: □ Yes □No__________________
vertical line. Washes & dries hands.
children (tag, tea parties, etc.)
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)
□ 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, no
to sounds, voice)
□ Nose (Mucosa NL, patent)
hip dysplasia
□ Mouth/Throat (MMM, palate intact, lips
□ Genitalia
& tongue NL, no oral lesions, no erythema)
Male (Penis NL: circ/uncir, no adhesions)
□ Teeth (Gums NL, dentition NL, no staining,
Female (Labia/clitoris NL, no discharge)
caries or white spots)
Assessment
Anticipatory Guidance
□ Behavior (Consistent discipline, temper tantrums, encourage play with
□ Well child
□ Normal growth and development
other children, emerging independence)
□ Safety (Bike helmet, car seats, second hand smoke, burns, smoke
detectors, drowning, poisoning, supervise, approaching new dogs)
□ Health Promotion (Family meals, healthy snacks, limit juice, brush teeth,
hand washing, daily physical activity, limit TV/screen time)
□ Development (Toilet training, playtime with other children, preschool,
language: read every day, model language, listen and respond to child, sing)
Plan
□ Education handout given
□ Immunizations (See immunization record)
□ Lead screen (If not done at 2 year)
□ Dental referral
Next Appointment: _________________ Signature: ___________________________ Date: _____________
1014.QI.P.FO 10/14
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