Pediatric Visit 6 To 11 Years Form
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1DATE OF SERVICE___________________
PEDIATRIC VISIT 6 to 11 YEARS
NAME____________________________________________
M / F
DATE OF BIRTH______________
AGE_____________
WEIGHT__________/_____%
HEIGHT__________/_____%
BMI ______/______%
TEMP______________
BP_____________
(note changes)
HISTORY REVIEW/UPDATE:
NUTRITIONAL ASSESSMENT:
Medical history updated? ______________________________
Typical diet
:
(specify foods)
Family health history updated? _________________________
Physical Activities:
Reactions to immunizations? Yes / No____________________
At least 1hr. exercise daily? Yes / No
Concerns: _________________________________________
Education: Choose foods from food guide pyramid
Sociable at table
Lowfat food choices, including milk
Choose healthy foods at school
PSYCHOSOCIAL ASSESSMENT:
Child care:
5 fruits/vegetables daily
No sweetened beverages
2hrs or less TV
Recent changes in family:
(circle all that apply)
:
DEVELOPMENTAL SURVEILLANCE
New members, separation, chronic illness, death, recent move,
School:
Grade:
Performance:
loss of job, other___________________________
Peer Relations:
Environment: Smokers in home? Yes / No
Family Relations:
Violence Assessment:
Extracurricular activities:
History of injuries, accidents? Yes / No
Misc. issues:
Evidence of neglect or abuse? Yes / No
ANTICIPATORY GUIDANCE:
RISK ASSESSMENT:
CHOL
TB
Social: Responsibility for self , for school
Competitiveness
Pos / Neg
Pos / Neg
(Circle)
Family vs. peer activities
Caution with strangers/animals
Teach address and phone number
MENTAL HEALTH ASSESSMENT:
Parenting: Increased autonomy in decisions
Communicate
Problem identified? Yes / No _________________________
Praise and encourage
Give allowance
Counseling provided? Yes / No _______________________
Assist in handling money
Establish fair rules
Referral? Yes / No To: ______________________________
Play and communication: Organized sports
Hobbies
PHYSICAL EXAMINATION
Monitor TV use
Wnl
Abn
(describe abnormalities)
Health: Dental care
Fluoride
Personal hygiene
Appearance/Interaction
Physical activity
Smoking
Second hand smoke
Growth
Use sunscreen
Tick prevention
________________________________
Skin
Sexuality: Prepare for physical changes
Early sex education
________________________________
Masturbation
Modesty
Head/Face
Injury prevention: Seat belt
Rear seat until age 12 years
Eyes/Red reflex
Riding toys in traffic environment
Bicycle helmets
Water safety
Cover test/Eye muscles
Hot water 120º
Fall prevention (playground)
Matches
Ears
Protective devices in sports
Smoke detector/escape plan
Nose/Mouth/Gums/Dentition
Poisoning (Plants, drugs, products)
Poison control #
________________________________
Firearms (look alike toys; owner risk/safe storage)
Neck/Nodes
Lungs
PLANS/ORDERS/REFERRALS
________________________________
1. Review immunizations and bring up to date ___________________
Heart/Pulses
2. Objective Hearing and Vision Tests
_______________
(recommended)
Chest/Breasts
3. PPD, if positive risk assessment
___________________________
________________________________
Abdomen
4. Testing/counseling, if positive cholesterol risk assessment _______
Genitals/Tanner stage
5. Dental visit advised
or date of last visit______________________
________________________________
6. Next preventive appointment at ______________________________
Musculoskeletal
7. Referrals for identified problems: Yes / No (specify)______________
Neuro/Reflexes
__________________________________________________________
________________________________
Vision (gross assessment)
__________________________________________________________
Hearing (gross assessment)
________________________________________________
__________________________________________________
Signatures:____________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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