Well Child Visit Form - 1-2 Months

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Well Child Visit: 1-2 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
Gest. Age: □ Term or ______weeks
Sleep: □ NL______________________
□ Breastfeeding
□ Supplementing/Both
□ Back to sleep
□ Formula (type): ________________
Birth Wt.:_________________
Newborn hearing screen: □ NL _________
□ Sleeps in own crib
Frequency: ____________________________
Elimination: □ NL _________________
WIC: □ Yes □No
Hep B vaccine: ___/____/_____
Recent illness: : □ Yes □No ____________
Behavior: □ NL ___________________
Water Source: _____________ Vit.: ______
__________________________________
Concerns:_____________________________
Car Seat Rear-facing: □ Yes □No _____
Social / Family History
Growth-Development
Cognitive: □ NL ________________
Language: □ NL ________________
Lives at home with:_________________________________
● indicates boredom (crying/fussy)
● coos, different cries for
Maternal Depression: □ Yes □No ______________________
when no change in activity
different needs
Parent/ child interaction: □ Yes □No ___________________
Tobacco smoke exposure: □ Yes No__________________
Physical: □ NL _________________
Social: □ NL __________________
Parents working outside home:
□ Mother □ Father
●able to hold head up,
● smiles, able to console/comfort
Child Care: □ Yes □No__________________
↓newborn reflexes
self, looks toward parent
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 strength/tone,
to sound, voice)
□ Nose (Mucosa NL, septum NL, patent)
No Ortolani or Barlow sign, no torticollis)
□ Mouth (MMM, palate intact, lips NL,
□ Genitalia
Male (Penis NL: circ/uncir, no adhesions, testes ↓)
tongue / frenulum NL, no oral lesions)
□ Throat (No erythema)
Female (No adhesions, labia/clitoris NL, no
discharge)
Assessment
Anticipatory Guidance
□ Well child
□ Family Transition (Sleep when baby sleeps, baby blues, support network)
□ Parent/Child interaction (Play time, singing, bonding, routines)
□ Normal growth and development
□ Safety (Back to sleep, car seats, avoid smoke exposure, crib safety, burns,
smoke detectors, drowning, no shaking)
□ Nutrition (Feeding cues, do not prop bottle, elimination, delay introducing
solid foods, choking)
□ Development (Milestones, tummy time, calming skills)
Plan
□ Immunizations (See immunization record)
□ Education handout given
Next Appointment: _________________ Signature: ___________________________ Date: _____________
1014.QI.P.FO 10/14

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