Well Child Visit - 18 Months
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1Well Child Visit: 18 Months
Name: ___________________________________
DOB: ________________ Date: __________________
Current Medications
Drug/Food Allergies
Accompanied By
Age
Ht.
Wt.
HC
Pulse
Resp.
Interpreter: Y / N
□M
□F
Past Medical History
Interval History
Nutrition
Recent illness : □ Yes □No ____________
□ Milk: __________ # oz/day :___________
Sleep: □ NL______________________
□ bedtime routine
Fruits: □ Yes □No ___ Vegetables: □ Yes □No__
__________________________________
Reaction to previous IMMS □ Ye □No_____
Elimination: □ NL __________________
Meats: □ Yes □No ____
Vitamins:□Yes □No
F/u previous concern: □ None ___________
Behavior: □ NL ___________________
Healthy snacks: □ Yes □No
Juice: □Yes □No
____________________________________
Activity (playtime): □ NL ____________
Concerns:_____________________________
Social / Family History
Growth-Development
□ Structured developmental screening: □NL
Tool______________
Lives at home with:_________________________________
□ Autism-specific screen: □NL
Tool______________
Parent/ child interaction: □ Yes □No ___________________
Cognitive: □ NL ______________
Language: □ NL ______________
Tobacco smoke exposure: □ Yes □No__________________
● Identifies body parts; brings object
● Uses 10-20 words; gestures;
Parents working outside home: □ Mother
□ Father
from another room when asked
makes “sounds” of familiar animals
Child Care: □ Yes □No
Type: ______________________
Physical: □ NL _______________
Social: □ NL _________________
Family/ Work Balance: □ Yes □No__________________
● Walks up steps; runs; stacks
● Laughs in response to others;
2-3 blocks; uses a spoon and cup
is interactive or withdrawn
Parental concerns: _______________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Physical Exam (checked □ = normal)
Abnormal Findings
□ General (Alert, NAD)
□ 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,
to sounds, voice)
□ Nose (Mucosa NL, patent)
no 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 (Limit “no”, consistent discipline, temper tantrums, allow simple
□ Normal growth and development
choices, praise positive behavior)
□ Safety (Car seats, avoid smoke exposure, burns, smoke detectors,
drowning, poisoning, baby gates, supervise)
□ Nutrition (Family meals, avoid struggle over foods, health snacks, limit
juice, use of cup, brush teeth)
□ Development (Self-feeding, toilet training readiness, playtime, language:
read, sing, talk)
Plan
□ Education handout given
□ Immunizations (See immunization record)
□ Lead screen (If not done at 1-year visit)
Next Appointment: _________________ Signature: ___________________________ Date: _____________
1014.QI.P.FO 10/14
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