Well Child Visit: 15 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______________________
Fruits: □ Yes □No ___ Vegetables: □ Yes □No___
Reaction to previous IMMS □ Yes □No_____
□ bedtime routine
Meats: □ Yes □No ___
Vitamins:□Yes □No____
□ Sleeps in own crib
Healthy snacks: □ Yes □No
Juice: □Yes □No
F/u previous concern: □ None ___________
Elimination: □ NL ________________
Concerns:_______________________________
Behavior: □ NL __________________
____________________________________
Activity (playtime): □ NL ___________
Social / Family History
Growth-Development
Cognitive: □ NL ________________
Language: □ NL ________________
Lives at home with:_________________________________
● Follows simple commands;
● Brings objects over to show you;
Parent/ child interaction: □ Yes □No ___________________
scribbles
waves good-bye; understands “no”
Tobacco smoke exposure: □ Yes □No_________________
Physical: □ NL _________________
Social: □ NL __________________
Parents working outside home: □ Mother
□ Father
● Drinks from cup; walks well;
● Imitates activities; listens to a
Child Care: □ Yes □No
Type: ______________________
puts block in a cup
story; may help in the house
Family/ Work Balance: □ Yes □No__________________
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, lids
□ Abdomen (Soft, non-tender)
□ Skin (No rashes, no lesions)
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 NL,
□ 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
□ Discipline (Limit “no”, use descriptors, temper tantrums, praise positive
□ Normal growth and development
behavior, domestic violence)
□ Safety (Back to sleep, car seats, avoid smoke exposure, crib safety,
burns, baby-proof home, drowning, poisoning, baby gates, supervise)
□ Nutrition (Self-feeding, family meals, avoid struggle over foods, use of
cup, brush teeth)
□ Development (Sleep routine, stranger anxiety, temperament,
communication, read/play with baby, exploration and physical activity)
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