DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068J (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / PRESCHOOL VISIT
nd
(See 2
page for Anticipatory Guidance for Preschool)
Completion of this form is voluntary.
Patient Name
Date of Birth
Age
Height
Weight
BMI
Today’s Date
Accompanied by
BP
Urinalysis
Urine Culture
Pulse
Vision
R.
/
L.
/
Color
Hearing
Gross
Audiogram
Parental Concerns
Adjustment to exam
Activity
Diet and Eating Habits: Regular meals, snacks
Persistence — Attention Span
Sleep: Behavior at bedtime, naps, nightmares, facilities
Distractibility
Speech and Language
Activities: Quiet, active
Dental Referral
Sitter / Day Care / Nursery School: Name and hours
Note – Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Part
N
Abn
Toilet Training: Day, night
Skin: Color, texture
Head: Symmetry, color, scalp, hair
Eyes: EOM, pupils, cornea, conjunctiviae, fundi
Parents’ Description of Activities with the Child: Temperament and
Ears: Pinnae, canals, tympanic membranes
Discipline Used. General Mood, Reaction to New Situations, Intensity of
Nose: Nares and turbinates
Reactions, Persistence / Attention Span, Distractibility, and Peer
Mouth: Tongue, gums, number of teeth ( )
Relationships.
Throat: Pharynx, tonsils
Neck: Movements, thyroid
Nodes: Axillary, Cervical
Lungs
Heart: Rhythm, S1, S2, murmur
Problems Identified and Reviewed
Abdomen: Contour, mass
Genitourinary: Vagina, testes, urethral orifice, hernia
Neuromuscular: Equilibrium, motor strength, sensory
coordination, cranial, nerves, DTRs, Babinsky
Spine: Posture, hip and shoulder levels
Extremities: Gait, range of motion of joints
Anus: Rectal
Physical and Emotional Status
Sexual Development: (Describe)
Describe abnormal findings.
Parents Interactions with Child O = Observed
M = Mother
F = Father
NO* = Not observed here
Diet
O
NO*
Activity
Makes eye contact
Anticipatory Guidance: Obedience, discipline, consistency of approach,
Touches child
independence, biting, kicking, Safety: accidents, poisoning, PICA. Dental
Hovers over child
and personal care. Sex identification, nursery school and television.
Spontaneously identifies positive qualities
Review temperature taking, aspirin or acetaminophen dosages, care of
Limits activity by verbal command
minor infections. Blood lead test as needed.
Limits activity by physical action
Gives simple, short directions / explanations
Immunization
Drug Co. and Lot No.
Expiration Date
Reinforces behavior with approval and attention
Terminates activity with some forewarning
Allows child to separate and check back
Allows child to answer for self
Blood Lead Test Done if not done at age 1 or 2
Interrupts child’s conversation
SIGNATURE — Provider
Date Signed
Limits child’s exuberance
Other Observations
Development and Parent-Child Interactions
Return to clinic in _____ months.
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