Well Child Visit Form - 24 Months 2014
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1Well Child Visit: 24 Months
Name: ___________________________________
DOB: ________________ Date: __________________
Current Medications
Drug/Food Allergies
Accompanied By
Age
Ht.
Wt.
BMI
BMI %ile
HC
Interpreter: Y / N
□M
□F
Past Medical History
Interval History
Nutrition
Recent illness: □ Yes □No ______________
□ Milk: __________ # oz/day :___________
Sleep: □ NL________________________
Fruits: □Yes □No _____________________
□ bedtime routine
____________________________________
Child has dental home: □ Yes □No _______
Vegetables: □Yes □No_________________
Elimination: □ NL ____________________
F/u previous concern: □ None ___________
Meats: □ Yes □No ____
Vitamins:□Yes □No
Behavior: □ NL _____________________
____________________________________
Healthy snacks: □ Yes □No
Juice: □Yes □No
Play time >60 mins/day □ Yes □No _____
Screen time <2hr/day □ Yes □No ______
Concerns:_____________________________
Social / Family History
Growth-Development
□ Autism-specific screen: □NL
Tool________________
Lives at home with:_________________________________
Cognitive: □ NL ______________
Language: □ NL ______________
Parent/ child interaction: □ Yes □No ___________________
● Names 1 picture (dog, apple, etc.);
● Uses 2 word phrases; asks
Tobacco smoke exposure: □ Yes □No__________________
follows 2-step command
parent to read book; >50 word
Parents working outside home: □ Mother
□ Father
vocabulary
Child Care: □ Yes □No
Type: ________________________
Physical: □ NL _______________
Social: □ NL __________________
Family/ Work Balance: □ Yes □No_____________________
● Stacks 5-6 blocks; can turn book
● Parallel play; ↑ pretend play;
pages one at a time
refers to self as “I” or “me”
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
□ Well child
□ Behavior (Consistent discipline, temper tantrums, encourage play with
□ Normal growth and development
other children, self-expression)
□ Safety (Bike helmet, car seats, second hand smoke, burns, smoke
detectors, drowning, poisoning, supervise)
□ Health Promotion (Family meals, healthy snacks, limit juice, brush
teeth, hand washing, daily physical activity, limit TV/screen time)
□ Development (Toilet training, playtime, follow 1-2 step commands, read
every day, model language, listen and respond to child, sing)
Plan
□ Education handout given
□ Immunizations (See immunization record)
□ Lead screen
□ Dental referral
Next Appointment: _________________ Signature: ___________________________ Date: _____________
1014.QI.P.FO 10/14
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