General Pediatric Clinic/6 Month Visit
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068D (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 6 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 6 Month Visit)
Completion of this form is voluntary.
Patient Name
Date of Birth
Age
Height
Weight
Today’s Date
Accompanied by
Head Circumference
Parental Concerns
Alertness
Activity
Feeding: Milk: Type _____________________oz./ day ______________
Juice ____________ Water ______________ x /day
Vitamins ___________ Fluoride ___________ Iron ____________
Reaction
Solids: Type and Meals/ Day
Sleep: Patterns, Facilities, and Hours
Note – Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Part
N
Abn
Skin
Skin: Color, texture, hair, scalp
Head and Face: Symmetry, Af size _____ cms _____
Eyes: Pupils, conjunctivae, EOM, red reflex
Teething
Ears & Nose: Canals, tympanic membranes, turbinates,
localization of sound
Mouth & throat: Tongue, pharynx, number of teeth ( )
Neck and Chest
Reaction to Previous Immunizations
Heart and Lungs: Rhythm, S1, S2, Murmur ( )
Abdomen & Spine: Contour, palpation
Extremities: Hips, tibiae, feet standing position
Family Routine with Baby
Genitourinary: Hernia, foreskin retraction, vagina
Neuromuscular: Tone, C2 – C12, reflexes, DTRs
Parents’ Description of Baby’s Temperament
Tonic neck ( ) Placing ( ) Palmar grasp ( )
Babinski ( ) Moro ( )
Problems Identified and Received
Describe abnormal findings.
Physical and Emotional Status
R = Reported O = Observed
Development Observation
Diet: Finger Foods, Cup, Start Wheat
R
O
NO*
NO* = not observed by parents or examiners.
G.M.
Pulled to sitting, has no head lag
Anticipatory Guidance: Night Awakening, Bed Time Routine.
Sits
alone
Fear of Strangers, Separation Anxiety.
Bears some weight on legs
Safety: Poisonings, Use of Syrup of Ipecac, Poison Control Phone
Stands holding on
Number. Crawling, Rolling, Reaching. Coffee Cups, Table Cloths.
Pulls to standing
Pot Handles, Cupboards, Sockets & Cords, Glass Objects, Plants,
P.M.
Hands generally open
Shoes, Teething, Walker
Passes toy from hand to hand
In sitting position, looks for toy
Immunization
Drug Co. and Lot No.
Expiration Date
In sitting position, takes 2 cubes
Lang.
Turns to voice
Imitates speech sounds
Mama & Dada nonspecific
P.S.
Turns away from strangers (cries)
Puts objects in mouth
Grasps object and resists pull
SIGNATURE — Provider
Date Signed
Works towards object just out of reach
Plays simple repetitive game (e.g., pat-a-cake)
O = Observed
M = Mother
Parents’ Interactions with Baby
O
NO*
F= Father
NO* = Not observed here
Makes eye contact with baby
Return to clinic in _____ months.
Responds only when baby cries
Sits back during exam
Physically attempts to calm baby
Spontaneously identifies positive qualities
Responds to baby’s vocalization with a vocal response
Hovers over baby
Consoles baby who shows reservation of stranger
Other Observations
Development and Parent-Child Interaction
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