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History
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Infant Gender
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Current Age
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Weight
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Height
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Head Circumference
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Concerns and questions
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Follow-up on previous Concerns
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Social/Family History/Situation
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Child lives with whom?
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If other, who?
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Review of Systems
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Supplements
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Nutrition
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Formula
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Hours between feedings
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Ounces/feed
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Behavior WNL?
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Feedings/24 hours
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Elimination WNL?
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Sleep WNL?
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Receiving WIC?
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Referred to WIC?
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Toxic Exposure: Passive Smoking
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Comments
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Development Assesment
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Lifts head and chest while prone
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Eyes follow to midline
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Looks at faces
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Responds to sound
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Additional Comments
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Physical Exam
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Appearance Normal?
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Appearance Comments
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Skin Normal?
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Skin Comments
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Head Normal?
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Head Comments
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Eyes Normal?
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Eyes Comments
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Ears Normal?
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Ears Comments
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Nose Normal?
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Nose Comments
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Mouth/Throat/Teeth/Gums Normal?
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Mouth/Throat/Teeth/Gums Comments
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Nodes Normal?
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Nodes Comments
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Heart Normal?
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Heart Comments
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Lungs Normal?
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Lungs Comments
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Abdomen (inc. Cord) Normal?
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Abdomen Comments
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Femoral Pulse Normal?
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Femoral Pulse Comments
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External Genitalia Normal?
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Ext. Genitalia Comments
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Hip Abduction Normal?
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Hip Abduction Comments
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Extremities Normal?
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Extremities Comments
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Spine Normal?
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Spine Comments
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Neuro Normal?
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Neuro Comments
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Testicles descended
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Other Comments
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Anticipatory Guidance
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Nutrition
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Parental Well-being
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Injury Prevention
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Plan
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Plan
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Plan Comments
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Discussed Worsening Symptoms?
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Referrals
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Labs Ordered
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Sleep position
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Previous Lab Results
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Follow-up/Next visit
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Final Check
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Discussed condition?
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D/W whom?
• • •
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Chart History Reviewed?
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