Well Child Exam - Infancy: Newborn-1 Week Visit - Ohio Department Of Job And Family Services Page 2
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3WELL CHILD EXAM-INFANCY: Newborn–1 Week Visit
DATE
PATIENT NAME
DOB
Developmental Questions and Observations
Ask the parent to respond to the following statements about the infant:
Yes
No
□
□
Please tell me any concerns about the way your baby is behaving or developing:
_________________________________________________________________________________
□
□
My baby looks at me and listens to my voice.
□
□
My baby calms down when picked up.
□
□
My baby is sleeping well.
□
□
My baby is eating well, sucking well.
□
□
My baby can hear sounds.
□
□
My baby looks at my face.
Ask the parent to respond to the following statements:
Yes
No
□
□
I am sad more often than I am happy.
□
□
I have more good days with my baby than bad days.
□
□
I have people who help me when I get frustrated with my baby.
Provider to follow up as necessary
Developmental Milestones
Always ask parents if they have concerns about development or behavior. (You may use the following screening list, or a
standardized developmental instrument or screening tool. Tool Used;__________________________________________).
Infant Development
Parent Development
Infant responds to soothing
Yes
No
Looks at infant
Yes
No
Infant listens to voices
Yes
No
Picks up and soothes infant
Yes
No
Infant fixates on human face,
Yes
No
Listens to infant
Yes
No
follows with eyes
Lifts head momentarily
Yes
No
Talks to infant
Yes
No
Moves arms, legs, and head
Yes
No
Touches infant
Yes
No
Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for
continuing observation is not anticipated. (Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents)
Additional Notes from pages 1 and 2:
Staff Signature: ________________________________ Provider Signature: ____________________________________
This screening form was adapted by the Ohio Medicaid managed care plans and Ohio Department of Job and Family Services for the
Healthchek-EPSDT Collaborative Performance Improvement Project.
040110
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