Form F-01068a - General Pediatric Clinic / 3-4 Week Visit
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068A (01/11)
GENERAL PEDIATRIC CLINIC / 3 – 4 WEEK VISIT
nd
(See 2
page for Anticipatory Guidance for 3 – 4 Week Visit)
Completion of this form is voluntary.
Patient Name
Date of Birth
Gender
Age
Height
Weight
Birth Weight
Today’s Date
Accompanied by
Head Circumference
Parental Concerns
Alertness
Activity
Pertinent Perinatal History (see Perinatal visit)
Response to Examiner
Note — Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
N
Part
Feeding
Skin: Color, texture, scalp, hair
Breast ________________ x / day, _______________ hours
Head: Shape, Af size ______ cms, facial symmetry
Formula: Type _____________________________________
Eyes: Palpebral fissures, red reflex, conjunctivae,
Amount / Feeding __________________ oz. x / day _____________
pupils, tear ducts
Water Given _____________________________________________
Ears: Canals, tympanic membrane,
responds to sound ( )
Nose: Air flow, nares
Sleeping Pattern
Mouth: Gums, tongue, frenulum, palate
Throat: Uvula, pharynx
Neck: Position, movement, thyroid
Skin Condition
Chest: Symmetry of movement, clavicals, sternum
Heart: Rhythm, S1, S2, Tones, murmur
Lungs: Breath sounds
Umbilicus
Abdomen: Contour, umbilicus, LSK
Extremities: Range of motion of arms and legs
Hips — abduction, leg length, click, gluteal folds
Stock Pattern
Genitourinary: Urinary stream, vagina, testes
Neuromuscular: Tone, posture, head control, fisting
Reflexes: Moro Suck Root
T onic Neck Steeping
Parents’ Description of Baby’s Temperament
Crying, activity, mood, reaction to new situations
Palmar Grasp
Plantar Grasp Babinski Placing
Ankle jerk
Pertinent Family History
Describe abnormal findings.
R = Reported
O = Observed
Developmental Observations:
R
O
NO
NO = Not Observed by Parents or Examiners
G.M.
Baby Prone, Lifts, and Turns Head
Neonatal Screen Checked
Baby Prone, Head Up 45
F.M.
Eyes Follow Object or Person to Midline
Eyes Follow Object or Person Past Midline
Physical and Emotional Status
LANG.
Quiets in Response to Voice or Noise
Vocalizes Spontaneously
Problems Identified and Reviewed
Vocalizes Responsively
Diet: Vitamins, fluoride, frequency of feedings
P.S.
Seeks Eye Contact
Smiles Responsively
Smiles Spontaneously
Anticipatory Guidance: Clothing, breathing, crying, outings, look for
O = Observed
M = Mother
Parents’ Interactions with Baby:
response to noise. Holding baby: Mom knows or shown. Use of bulb syringe
O
NO
F = Father
NO = Not Observed Here
for nose: Mom knows or shown. Temperature taking: Mom knows or shown.
Makes Eye Contact With Baby
Safety: falls, cribsides, sibs feeding baby, car seat, care while bathing. Home
Talks to Baby
water temperature. Immunization plan.
Changes Position of Baby Frequently
Bounces or Pats Baby (Baby Quiet)
SIGNATURE — Provider
Date Signed
Responds Only to Baby’s Crying
Sits Back During Exam
Other Observations
Development and Parent-Child Interactions
Return to Clinic in _________________ months.
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