|
History
|
|
|
Concerns and questions
|
Follow-up on previous Concerns
|
|
History Interval Change
|
History Interval Change
|
|
|
|
|
Social/Family History/Situation
|
|
|
Family Situation Interval Change
|
Family Situation Interval Change
|
|
Child lives with whom?
|
|
|
Parents working outside home
• • •
|
Work plans
|
|
Child Care
|
Type
|
|
Pets in house
• • •
|
Pet Comments
|
|
Changes since last visit
|
Screened for Domestic Violence?
|
|
|
|
|
Review of Systems
|
|
|
Interval Change
|
Changes since last visit
|
|
Nutrition
|
Supplements
• • •
|
|
Milk
|
Ounces/day
|
|
Solid foods
|
Juice
|
|
Source of water
|
|
|
Receiving WIC?
|
Referred to WIC?
|
|
Elimination WNL?
|
Comments
|
|
Sleep WNL?
|
Comments
|
|
Behavior WNL?
|
Comments
|
|
Toxic Exposure: Passive Smoking
|
Toxic Exposure: Lead
|
|
TB risk
|
|
|
|
|
|
Development Assesment
|
|
|
Gross Motor
• • •
|
Fine Motor
• • •
|
|
Communication
• • •
|
Social
• • •
|
|
|
|
|
Physical Exam
|
|
|
Appearance Normal?
|
Appearance Comments
|
|
Skin Normal?
|
Skin Comments
|
|
Head Normal?
|
Head Comments
|
|
Eyes Normal?
|
Eyes Comments
|
|
Ears Normal?
|
Ears Comments
|
|
Nose Normal?
|
Nose Comments
|
|
Mouth/Throat/Teeth/Gums Normal?
|
Mouth/Throat/Teeth/Gums Comments
|
|
Nodes Normal?
|
Nodes Comments
|
|
Heart Normal?
|
Heart Comments
|
|
Lungs Normal?
|
Lungs Comments
|
|
Abdomen Normal?
|
Abdomen Comments
|
|
Femoral Pulse Normal?
|
Femoral Pulse Comments
|
|
External Genitalia Normal?
|
Ext. Genitalia Comments
|
|
Hip Abduction Normal?
|
Hip Abduction Comments
|
|
Extremities Normal?
|
Extremities Comments
|
|
Spine Normal?
|
Spine Comments
|
|
Neuro Normal?
|
Neuro Comments
|
|
Other
|
Other Comments
|
|
|
|
|
Assessment
|
|
|
Well Child?
|
Further Comments
|
|
|
|
|
Anticipatory Guidance
|
|
|
Nutrition
• • •
|
Dental Care
• • •
|
|
Elimination
• • •
|
Sleep
• • •
|
|
Behavior and Development
• • •
|
Family Relationships
• • •
|
|
Injury Prevention
• • •
|
|
|
|
|
|
Plan
|
|
|
Plan
• • •
|
Plan comments
|
|
Discussed Worsening Symptoms?
|
Referrals
• • •
|
|
Labs Ordered
• • •
|
Additional
|
|
Previous Lab Results
|
Follow-up/Next visit
|
|
|
|
|
Immunizations
|
|
|
Immunizations Administered
• • •
|
Immunization Status
|
|
|
|
|
Final Check
|
|
|
Discussed condition?
|
D/W whom?
• • •
|
|
Chart History Reviewed?
|
|
