|
family history
• • •
|
perinatal history
• • •
|
|
Immunization Reaction history
• • •
|
Concerns
|
|
SLEEP
|
Child care
• • •
|
|
changes in family
• • •
|
OTHER
|
|
Smoking YES
|
Smoking NO
|
|
Injuries/accidents
• • •
|
Abuse/neglect
• • •
|
|
Lead risk
• • •
|
|
|
APPEARANCE/INTERACTION
|
LUNGS
|
|
GROWTH
|
HEART/PULSES
|
|
SKIN
|
CHEST/BREASTS
|
|
HEAD/FACE/FONTANELLES
|
ABDOMEN
|
|
EYES/RED REFLEX/COVER TEST
|
GENITALS/CIRCUMCISION
|
|
EARS
|
EXTREMITIES/HIPS/FEET
|
|
NOSE
|
NEURO/REFLEXES/TONE
|
|
MOUTH/GUMS/NUMBER OF TEETH
|
VISION (GROSS ASSESSMENT)
|
|
NECK/NODES
|
HEARING (GROSS ASSESSMENT)
|
|
Abnormal Description
|
|
|
FEEDING AMOUNT/FREQUENCY
/
|
|
|
Wet/Dry diapers
/
|
total # BM's
|
|
EDUCATION TOPICS
• • •
|
New Field
|
|
DEVELOPMENT
• • •
|
NO SOCIAL DEVELOPMENT
|
|
FINE MOTOR
• • •
|
FINE MOTOR NO
|
|
LANGUAGE
• • •
|
NO LANGUAGE PROGRESS
|
|
GROSS MOTOR
• • •
|
NO GROSS MOTOR
|
|
ANTICIPATORY GUIDANCE
• • •
|
PARENTING
• • •
|
|
PLAY/COMMUNICATION
• • •
|
HEALTH ANTICIPATORY GUIDANCE
• • •
|
|
INJURY PREVENTION
• • •
|
|
|
Immunizations/Plans
• • •
|
SCREENINGS/APPOINTMENTS
• • •
|
|
REFERRALS
|
|
|
Dr. Name
|
|
|
|
|
|
Autism Screening
|
|
|
Can you tell if Happy/upset
• • •
|
Check to see if you are watching
• • •
|
|
Smile/laugh when looking at you
• • •
|
Point/look at object across room
• • •
|
|
Do they ask for help
• • •
|
Do they try to get your attentio
• • •
|
|
Do stuff to make you laugh
• • •
|
Try to get you to notice objects
• • •
|
|
Do they pick up & give you objec
• • •
|
Do they show you objects
• • •
|
|
Do they wave to greet people
• • •
|
Do they point to objects
• • •
|
|
Can they nod head yes
• • •
|
Use sounds/words to get attentio
• • •
|
|
String sounds together (uh oh)
• • •
|
How many consonant sounds
• • •
|
|
How many meaningful words
• • •
|
Do they put 2 words together
• • •
|
|
Do they look when spoken to
• • •
|
Do they understand you
• • •
|
|
Play w/ variety of objects
• • •
|
Do they use objects correctly
• • •
|
|
Can stack how many blocks
• • •
|
Pretend play
• • •
|
|
Any Concerns
|
|
