General Pediatric Clinic / 4 Month Visit
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-1068C (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 4 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 4 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: Breast________________ x / day. ____________Hours
Formula: Type _____________ (
) ______________x / day
Amount / Feeding ____________ oz. Water ___________x / day
Response to Examiner
Solids
Sleeping
Note — Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Skin
Part
N
Abn
Skin: Color, texture
Head: AP size _____ / cms _____
Eyes: Cover test, lids, pupils, conjunctivae, red reflex, fundi
Stool Pattern
Ears: Canals, tympanic membranes, localization of sound
Nose, Mouth, Throat: Gums, Buccal mucosa, tongue
Neck & Chest: Trachea, thyroid, cervical nodes
Reaction to Previous Immunization
Heart and lungs
Abdomen: Size, liver, spleen, kidneys
Current Living Situation
Extremities: Hips — abduction _________ click ( )
Tibial malleolar positions _________ feet __________
Parents’ Description of Baby’s Temperament
Genitourinary: Penis, meatus, foreskin retraction, testes
Vaginal orifice, inguinal nodes, inguinal hernia ( )
Problems Identified and Received
Neuromuscular: Tone, posture, head control, motor strength,
C2 – 12, reflexes, moro ( ) placing ( ) palmar grasp ( )
planter grasp ( ) tonic neck ( ) babinski ( ) DTRs
Physical and Emotional Status
Describe abnormal findings.
Diet: Change in Stool with Diet, Scheduling to Fit Family Schedule
Development Observation NO* = not observed by parents or examiners,
Additions
R
O
NO*
R = Reported, O = Observed
G.M.
Rolls over from stomach to back
Prone, lifts, chest up with arm support
Anticipatory Guidance: Drooling, Chewing, Teething, Pacifier.
Colds and Fever Review
No head lag when pulled to sitting
Sibling Rivalry. Vocal Stimulation
Head steady when held sitting
Safety: Need for Safe Place to have Baby, Toys.
Bears some weight on legs
Aspiration of Foreign Objects. Home Water Temp.
P.M.
Regards & follows small object — 90 degree arc
Reaches for dangling object
Immunization
Drug Co. and Lot No.
Expiration Date
Brings hands together
Grasps objects and resists pulls
Lang.
Laughs aloud
Vocalizes responsively
Initiates vocalization
SIGNATURE — Provider
Date Signed
P.S.
Seeks eye contact with parents
Reaches with arms to parents
Smiles responsively
Return to clinic in _____ months.
Parents’ Interactions with Baby NO* = Not observed here
O
NO*
O = Observed M = Mother F= Father
Touches baby
Scolds crying baby
Calmly holds to quiet baby
Spontaneously identifies baby’s positive qualities
Watching baby’s actions during visit
Responds to baby’s voice with vocal response
Other Observations
Development and Parent-Child Interaction
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