General Pediatric Clinic / 18 Month Visit
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068H (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 18 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 18 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
Adaptability to Exam
Activity
General Health
Distractibility
Words Spoke
Note – Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
General Behavior
Part
N
Abn
Skin: Color, texture
Head and Face: Symmetry, AF size _____ cm _____
Eyes: Pupils, conjunctive, EOM,, red reflex
Peer Interactions
Ears and Nose: Canals, Tympanic membranes, tubinates
Nose: Discharge
Eating Habits: Diet, behavior at meals
Mouth: Gums, tongue, number of teeth
Nodes: Cervical, inguinal
Lungs
Heart: Rhythm, S1, S2 murmur
Parents’ Perception of Child’s Temperament
Abdomen: Contour, masses, hernia
Genitalia: Vaginal opening, testes ( ) ( )
Extremities: Range of motion, stance
Neuromuscular: Tone, strength, equilibrium, coordination,
Problems Identified and Reviewed
gait, DTRs
Describe abnormal findings.
Physical and Emotional Status
R = Reported O = Observed
Development Observation
R
O
NO*
NO* = not observed by parents or examiners
G.M.
Walks backwards
Diet: Snacks, pickiness, independent feeding
Walks up steps without holding on
Walks up steps with help
Kicks a ball forward
Throws a ball over head
P.M.
Scribbles with a pencil
Anticipatory Guidance: Discipline, limit setting, obedience, temper
Makes a tower of two cubes
tantrums, toilet training, peer activities.
Makes a tower of four cubes
Safety: Climbing, stove, water, poisons, plants, street, need for supervision,
Says ten single words besides Mama & Dada
Lang.
car seats, lead exposure.
Combines two different words together
Names one picture
Immunization
Drug Co. and Lot No.
Expiration Date
Puts a toy under the table
Puts a toy on the floor
Gives a toy to the mother
P.S.
Removes own clothing
SIGNATURE — Provider
Date Signed
Imitates simple housework
Uses spoon with spilling
Comforted by touches parents
Comforted by parent’s voice
Return to clinic in _____ months.
Will not go to strangers
Parents’ Interactions with Child O = Observed
M = Mother
F= Father
NO* = Not observed here
O NO
*
O NO
*
Gives simple, short directions/explanations
Ignores temper tantrum
Voice calm when talking to child
Interrupts temper tantrum physically
Reinforces behavior through approval and attention
Interrupts temper tantrums verbally
Terminates activities with some forwarding
Calmly holds to quiet
Other Observations
Development and Parent-Child Interaction
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