General Pediatric Clinic / 9 Month Visit
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068E (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 9 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 9 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: Milk, type ___________ Amt / day ___________oz.
Bottle ______ Cup ______ Self Feeding _________
Adaptability to Examination
Solids: type & meals / day
Sleeping: Behavior at naps, bedtime
Note — Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Part
N
Abn
Skin: Color, texture, scalp, bruises, scars
Head & Face: Symmetry, AF open ( )
Eyes: Pupils, conjunctivae, EOM, peripheral vision
Family Activity with Baby
Ears & Nose: Canals, tympanic membranes, turbinates,
nodes
Mouth & Throat: Tongue, pharynx, number of teeth ( )
Neck & Chest
Parents’ Description of Baby’s Temperament
Reaction to new situations, adaptability, persistence / attention
Heart & Lungs: Rhythm, S1, S2, Number ( )
Span, distractibility, threshold level
Abdomen & Spine: Contour, palpation
Extremities: Hips, tibiae, feet, standing position
Genitourinary: Testes ( ), foreskin, retraction, vagina
Neuromuscular: Tone, C2 – 12, reflexes, DTRs, babinski
Problems Identified and Reviewed
Nodes
Describe abnormal findings.
Physical and Emotional Status
Diet: Use of spoon and cup, finger foods, add egg whites,
R = Reported.
O = Observed
Development Observation
normal drop in appetite
R
O
NO*
NO* = not observed by parents or examiners,
G.M.
Stands holding on
Anticipatory Guidance: Discipline, limit setting, clinging, fear of
Pulls to standing
strangers, bedtime and nap routines
Walks holding on to furniture
Safety: Stairs, fans, heaters, drawers, pins, nuts, paint,
Gets to sitting
plants.
Crawling on hands and knees
Syrup of Ipecac. Car seat. Home water temp.
P.M. Thumb-finge
r grasp
Holds two cubes, bangs them together
SIGNATURE — Provider
Date Signed
Lang. Babbles
Ma, Dada, nonspecific
P.S.
Initially shy with strangers
Plays repetitive game (e.g., Pat-a-cake, bye bye)
Return to clinic in _____ months.
Feeds self using fingers
Parents’ Interactions with Baby O = Observed
M = Mother
O
NO*
F= Father
NO* = Not observed here
Touches baby
Talks to baby
Spontaneously identifies positive qualities of baby
Responds verbally to baby’s vocalization
Limits activity by physical actions
Limits activity by verbal command
Allows baby to explore
Calmly holds to quiet baby
Consoles baby who shows reservations of strangers
Other Observations
Development and Parent-Child Interaction
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