Well Child Visit Form - Newborn
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1Well Child Visit: Newborn
Name: ___________________________________
DOB: ________________ Date: __________________
Current Medications
Drug Allergies
Accompanied By
Age
Ht.
Wt.
HC
Pulse
Resp.
Temp.
Interpreter: Y / N
□M
□F
Past Medical History
Interval History
Nutrition
□ Breastfeeding
□ Supplementing/Both
Sleep: □ NL_______________
Gestational Age: □ Term or _________weeks
□ Back to sleep
□ Formula (type): ________________
Birth Wt.:________ Wt. @ discharge: _______
□ Sleeps in own crib
Elimination: □ NL ______________
Frequency: __________________________
Mode of delivery: ____________________
Newborn hearing screen: □ NL _________
WIC: □ Yes □No
Behavior: □ NL ________________
Hep B vaccine: ___/____/__________
Water Source: _____________ Vit.: ______
Car Seat Rear-facing: □ Yes □No
Concerns:_____________________________
__________________________
Social / Family History
Growth-Development
Cognitive: □ NL _____________
Language: □ NL _______________
Lives at home with:____________________________________
● Follows face to midline
● Turns and calm to parent’s voice
Parents adjusting: □ Yes □No __________________________
Maternal Depression: □ Yes □No ________________________
Physical: □ NL ______________
Social: □ NL __________________
Parent/ child interaction: □ Yes □No ______________________
●Able to suck, swallow, and
● Stretches of sleep
Tobacco smoke exposure: □ Yes □No____________________
breathe; strong root reflexes
Significant Family Medical History: □ Yes □No______________
____________________________________________________
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
□ Abdomen (Umbilical cord NL)
□Skin (No rashes, no jaundice)
NL, conjunctivae/sclera clear)
□ Ears (Canals clear, TMs NL,
□ Extremeties (Full ROM, strength/tone NL,
orients to sound, voices)
no Ortolani or Barlow sign)
□ Nose (Mucosa NL, patent)
□ Genitalia
□ Mouth (MMM, palate intact,
Male (Penis NL: circ/uncir, no adhesions,
testes ↓)
tongue/frenulum NL , no lesions)
□ Neuro (Tone, symmetry, strength
Female (No adhesions, labia/clitoris NL, no
all NL)
discharge)
Assessment
Anticipatory Guidance
□ Family Transition (Sleep when baby sleeps, baby blues, routines,
□ Well child
□ Normal growth and development
support network)
□ Safety (Back to sleep, car seats, second-hand smoke, crib safety,
water temperature, smoke detectors, no shaking)
□ Nutrition (Feeding cues, burping, do not prop bottle, wet/dirty diapers
per day, lactation counseling)
□ Newborn Care (Cord care, circumcision care, frequent hand washing,
skin care, emergency readiness)
Plan
□ Hep B Vaccine
□ Education handout given
Next Appointment: _________________ Signature: ___________________________ Date: _____________
.
0814.QI.P.FO.2 10/14
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