DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 4 MONTH VISIT
page for Anticipatory Guidance for 4 Month Visit)
Completion of this form is voluntary.
Date of Birth
Feeding: Breast________________ x / day. ____________Hours
Formula: Type _____________ (
) ______________x / day
Amount / Feeding ____________ oz. Water ___________x / day
Response to Examiner
Note — Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Skin: Color, texture
Head: AP size _____ / cms _____
Eyes: Cover test, lids, pupils, conjunctivae, red reflex, fundi
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,
R = Reported, O = Observed
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.
Regards & follows small object — 90 degree arc
Reaches for dangling object
Drug Co. and Lot No.
Brings hands together
Grasps objects and resists pulls
SIGNATURE — Provider
Seeks eye contact with parents
Reaches with arms to parents
Return to clinic in _____ months.
Parents’ Interactions with Baby NO* = Not observed here
O = Observed M = Mother F= Father
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
Development and Parent-Child Interaction