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This is a 2 month old patient who presents for well child visit
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Previsit Questionnaire reviewed.
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Child has special health care needs
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Interval History (well no concerns)
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Interval History free text
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Concerns and questions:
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Follow up on previous concerns:
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New Short Text Field
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Medication record reviewed and updated.
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Social/Family History
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No interval change.
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Parental adjustment to child:
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Maternal depression:
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Work/child care plans
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Parents working outside the home:
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Child care:
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Changes since last visit:
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Sibling Adjustment comments:
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Review of Systems
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See interval history questionnaire and problem list.
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No interval change.
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Changes since last visit.
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Nutrition:
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type of nutrition
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Breast milk.
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Minutes per feeding:
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Hours between feeding:
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Feedings per 24 hours:
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Problems Breastfeeding (MS)
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Problems with breastfeeding
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Formula
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Formula type (MS)
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Type of formula
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Ounces per feeding:
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Source of water:
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Elimination MS
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Elimination:
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Sleep:
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Behavior:
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Development:
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Development screen type
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Physical development normal:
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Cognitive
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Communicative
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Social-emotional
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Physical Exam
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Growth Charts reviewed
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General WNL
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General Abnormal
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General Comments
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HEENT WNL
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HEENT Abnormal
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HEENT Comments (Fontanelle non bulging. Negative for positional skull deformities)
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Skin WNL
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Skin Lesion
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Skin Comments
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Neck WNL
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Neck Abnormal
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Neck Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
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Abdomen Comments
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MSK Barlow and Ortolani WNL
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MSK Abnormal
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MSK Comments
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Breasts WNL
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Breasts Abnormal
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Breasts Comments
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Neuro WNL
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Neuro Abnormal
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Neuro Comments
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Extremities WNL
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Extrem Abnormal
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Extrem Comments
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Male Genitalia b/l testes descended
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Female genitalia appears normal.
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ASSESSMENT
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Well Child Z00.129
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Assessment:
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Anticipatory Guidance
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Bright Futures Parent Handout 2 Month Visit Form given to parent.
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Parental (Maternal) Well-being
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Infant-family synchrony
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Nutritional Adequacy
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Infant Behavior
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Safety
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Plan:
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Immunizations (See vaccine administration record.)
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Laboratory/screening results
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Referral to
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Follow-up/Next Visit:
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Follow-up/Next Visit:
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