Well Child Exam - Infancy: 9 Months
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3WELL CHILD EXAM-INFANCY: 9 Months
DATE
PATIENT NAME
DOB
SEX
PARENT NAME
Allergies
Current Medications
Prenatal/Family History
Chief Complaints
Weight
Percentile
Length
Percentile
Wt for Length
HC
Percentile
Temp
Pulse
Resp.
BP (if risk)
Percentile
%
%
%
%
Interval History:
Anticipatory Guidance/Health Education
□ Y
□ N
Patient Unclothed
(√ if discussed)
(Include injury/illness, visits to other health
Review of
Physical
Safety
care providers, changes in family or home)
□ Appropriate car seat placed in back seat
Systems
Exam
Systems
□ Pool/water safety
N
A
N
A
□ Poison Control Center: 1-800-222-1222
General
□
□
□
□
□ Childproof home - (hot liquids, cigarettes,
Appearance
alcohol, poisons, medicines, outlets, gun
□
□
□
□
Skin/nodes
safety, cords, small/sharp objects, plastic
bags)
□
□
□
□
Nutrition
Head/fontanel
□ Never shake baby
□ Breast every ______ hours
□ Limit time in sun/use hat & sunscreen
□
□
□
□
□ Formula ____ oz every _____ hours
Eyes
□ Check home for lead poisoning hazards
With iron □ Y □ N
□
□
□
□
Ears
Type or brand
Nutrition
_____________________________
□
□
□
□
Nose
□ Breastfeed or give iron-fortified formula
□ City water
□ Well water
□ Encourage self-feeding, cup use
Solids □ Y □ N
□
□
□
□
Oropharynx
□ 3 meals and 2-3 snacks w/variety of foods
Elimination
□ Avoid foods that contribute to allergies
□ Normal
□ Abnormal
Gums/ palate/
□
□
□
□
□ Increase soft, moist table foods gradually
teeth
Sleep
□ Normal (8-10 hours at night) □ Abnormal
□
□
□
□
Neck
Infant Development
Additional area for comments on page 2
□ Talk, sing, play games and read to baby
□
□
□
□
Lungs
□ Consistent Daily/Bedtime Routine
WIC
□ Changing sleep patterns
□ Y □ N
□
□
□
□
Heart/pulses
□ Safe Exploration Opportunities
Maternal Infant Health Program
□
□
□
□
□ Play Pat a Cake, Peek a Boo, So Big
□ Y □ N
Abdomen
□ Crib Safety/lower mattress
□
□
□
□
□ Avoid TV, videos, computers
Genitalia
Screening and Procedures:
□ Oral Health Risk Assessment
□
□
□
□
Spine
Family Support and Relationships
□ Subjective Hearing -Parental observation/
□ Make time for self, partner, friends
concerns
□
□
□
□
Extremities/hips
□ Set examples and use simple words to
□ Subjective Vision -Parental observation/
discipline – don’t yell at, hit or shake baby
□
□
□
□
concerns
Neurological
□ Use consistent positive discipline
LABS_____________________
□ Abnormal Findings and Comments
□ Discuss baby’s explorations w/siblings
Standardized Developmental Screening
□ Chose responsible caregivers
□ Completed Tool Used_____________
□ Substance Abuse, Child Abuse, Domestic
RESULTS: □ No Risk □ At Risk
Violence Prevention, Depression
(see additional note area on next page)
Psychosocial/Behavioral Assessment
Other Anticipatory Guidance Discussed:
□ Y □ N
Results of visit discussed with parent □ Y □ N
□ Y □ N
Screening for Abuse
Plan
If At Risk
□ History/Problem List/Meds Updated
□ Lead level ______ mcg/dl
□ Referrals
Immunizations:
Next Well Check: 12 months of age
□ WIC
□ Help Me Grow □
□ Immunizations Reviewed
Transportation
A standardized developmental screening tool
□ Immunizations Given & Charted – if not
□ Maternal Infant Health Program (MIHP)
should be administered (Medicaid required and
given, document rationale
AAP recommended) at the 9 month visit.
□ Children Special Health Care Needs
Refer to AAP Guidelines
Provider Signature:
□ IMPACTSIIS checked/updated
□ Other referral_________________
□ Other ________________________________
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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