General Pediatric Clinic / 24 Month Visit

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068I (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 24 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 24 Month Visit)
Completion of this form is voluntary.
Patient Name
Date of Birth
Age
Height
Weight
BMI
Today’s Date
Accompanied by
Head Circumference
Reaction to Examination
Activity
Distractibility
Persistence / Attention Span
Intensity Level
Words Spoken, Sentence Length, Speech Clarity
Parental Concerns
Note – Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
General Health
Part
N
Abn
Skin: Color, texture, hair, scalp
Head & Face: Symmetry, AF size _____ cms _____
General Behavior: Behavior at meals
Eyes: Pupils, conjunctivae, EOM, red reflex
Ears and Nose: Canals, timpanic membranes, turbinates
Nose: Discharge
Sleeping
Mouth: Gums, tongue, number of teeth ( )
Nodes: Cervical inguinal
Lungs
Toilet Training: Bowel, bladder, day, night
Heart: Rhythm, S1m S2, murmur
Abdomen: Contour, masses, hernia
Genitalia: Vaginal opening, testes ( ) ( )
Peer and Social Opportunities
Extremities: Range of motion, stance
Neuromuscular: Tone, strength, equilibrium, coordination,
Gait, DTRs
Parents’ Description of Child’s Temperament
Describe abnormal findings.
Problems Identified and Reviewed
Development Observation
R = Reported
O = Observed
R
O
NO*
NO* = Not observed by parents or examiners
G.M.
Runs well
Development and Parent-Child Interactions
Jumps with both legs together
Balances on 1 foot for 1 -2 seconds
Kicks the ball forward
Physical and Emotional Status
Throws a ball overhand
Walks up the steps
Walks down the stairs
Pedals a vehicle
Anticipatory Guidance: Diet, snacks, independence, limit setting,
F.M.
Scribbles with a pencil
temper tantrums, peer companionship, sharing, taking turns, sleeping,
Copies a vertical line
crawling out of bed, night fears, naps, T.V., Dental care, Safety: Car sear,
Copies a circle
street, play, PICA, lead exposure.
Makes a tower out of four cubes
Immunization
Drug Co. and Lot No.
Expiration Date
Makes a tower out of eight cubes
Lang.
Has many single words
Combines two different words together
Points to and names part of the body
Names a picture
Uses plurals
 Blood Lead Test Done
Says own name
 Other Lab Tests __________________________________________
P.S.
Puts a toy under the table
SIGNATURE — Provider
Date Signed
Puts a toy on the floor
Gives the toy to the mother
Puts on some clothing alone
Uses spoons well, spilling very little
Washes and dries hands alone
Return to clinic in _____ months.
Plays games with others
Helps or mimics household tasks
Parents’ Interactions with Child
O = Observed
M = Mother
F= Father
NO* = Not observed here
O
NO*
O
NO*
Spontaneously identifies child’s positive qualities
Reinforces behavior through approval and attention
Limits activity by verbal command
Terminates activity with some forewarning
Limits activity by physical actions
Interrupts temper tantrums vocally
Gives simple short directions / explanations
Interrupts temper tantrums physically
Voice calm when talking to child
Allows to separate and check back
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