Well Child Visit Form - 3-4 Months
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1Well Child Visit: 3-4 Months
Name: ___________________________________
DOB: ________________ Date: __________________
Current Medications
Drug/Food Allergies
Accompanied By
Age
Ht.
Wt.
HC
Pulse
Resp.
Temp.
Interpreter: Y / N
□M
□F
Past Medical History
Interval History
Nutrition
Recent illness: : □ Yes □No ____________
□ Breastfeeding
□ Supplementing/Both
Sleep: □ NL______________________
□ Back to sleep
□ Formula (type): ______________________
__________________________________
Reaction to previous IMMS □ Yes □No____
□ Sleeps in own crib
Frequency: ____________________________
Elimination: □ NL _________________
WIC: □ Yes □No_______
Vit.: ________
F/u previous concern: □ None ___________
Behavior: □ NL ___________________
____________________________________
Car Seat Rear-facing: □ Yes □No _____
Concerns:_____________________________
Social / Family History
Growth-Development
Cognitive: □ NL ________________
Language: □ NL ________________
Lives at home with:_________________________________
● responds to affection, indicates
● different cries for different needs,
Parent/ child interaction: □ Yes □No ___________________
pleasure and displeasure
more expressive babbles
Tobacco smoke exposure: □ Yes □No__________________
Parents working outside home: □ Mother
□ Father
Physical: □ NL _________________
Social: □ NL __________________
Child Care: □ Yes □No
Type: ______________________
●good head control, reaches for,
● smiles, interacts, displays
Family/ Work Balance: □ Yes □No___________________
beginning to roll
self-consolation skills
Parental Concerns: ________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Physical Exam (checked □ = normal)
Abnormal Findings
□ General (Alert, NAD)
□ Heart (No murmurs, + femoral pulses)
□ Head (Fontanelle NL, symmetric)
□ Lungs (Clear breath sounds)
□ Eyes (PERRL, EOMI, + RR, lids NL,
□ Abdomen (Soft, non-tender)
□ Skin (No rashes)
conjunctivae/sclera clear)
□ Ears (Canals clear, TMs normal, orients
□ Neuro (Tone, symmetry, strength all NL)
□ Extremities (Full ROM, NL
to sound, voice)
□ Mouth (MMM, palate intact, lips NL,
strength/tone, No Ortolani or Barlow
tongue NL, no lesions)
sign, no torticollis)
□ Nose (Mucosa NL, septum NL patent)
□ Genitalia
□ Throat (No erythema)
Male (Penis NL: circ/uncir, no adhesions)
Female (No adhesions, labia/clitoris NL,
no discharge)
Assessment
Anticipatory Guidance
□ Family Health (Support network, work/life balance, community
□ Well child
□ Normal growth and development
resources)
□ Safety (Back to sleep, car seats, avoid smoke exposure, crib safety,
burns, smoke detectors, drowning, lead poisoning)
□ Nutrition (Introducing solid foods, choking, growth spurts)
□ Development (Milestones, tummy time, sleep, routines, social time)
Plan
□ Immunizations (See immunization record)
□ Education handout given
Next Appointment: _________________ Signature: ___________________________ Date: _____________
1014.QI.P.FO 10/14
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