Chief Concern
|
Accompanied by
|
Age
|
Primary Pediatrician
|
General Information
|
|
New patient - birth info
|
|
Birth provider
|
Location of Birth
|
Birth weight
|
Birth length
|
Discharge weight
|
Discharge Age
|
APGAR
|
2nd Metabolic Screening
|
OAE
|
Vitamin K
|
IM / Oral
|
Hep B
|
Eye ointment
|
Pregnancy/labor history
|
FHx
|
Antibiotic Hx
|
Allergies
|
Sleep/Naps
|
BMs- color and freq
|
Urination
|
Breast: every ___ hours
|
Breast ___ days
|
Breast for ___ mins
|
Latch/concerns
|
Bottle/Formula type
|
___ ounces?
|
____ hours?
|
|
Diet
|
Breakfast
|
Lunch
|
Snacks
|
Dinner
|
Food reactions
|
Beverages
|
Diet Comments
|
Immunizations
|
Immunization Comment
|
Review Of Systems
|
|
PFSH no change
|
PFSH : Comments
|
Constitutional(fever,sweats, chi
|
Constitutional : Comments
|
Eyes (pain, d/c, redness,vision)
|
Eyes : Comments
|
ENT (pain, d/c, ringing)
|
ENT : Comments
|
CV (palp, pain, SOB, DOE, Edema)
|
CV : Comments
|
Resp (SOB, wheeze, cough)
|
Resp : Comments
|
GI(N/V/D,pain,gas/bloat,constip)
|
GI : Comments
|
GU(freq/dys/urg, d/c, hematuria)
|
GU : Comments
|
Gyne(d/c,pain,change in menses)
|
Gyne : Comments
|
MSK(pain,swelling,loss of ROM)
|
MSK : Comments
|
Derm (rash, pruritis, redness)
|
Derm : Comments
|
Endo (wt change, goiter, hair lo
|
Endo : Comments
|
Heme/Lymph(easy bruising/bldg)
|
Heme/Lymph : Comments
|
Neuro (HA, N/T, coord/weakness)
|
Neuro : Comments
|
Sleep
|
Sleep Comments
|
Parental concerns
|
|
Pain Scale
|
Pain Scale Comments
|
Energy Scale
|
Energy
|
General Symptom Scale
|
General Information
|
Thyroid Sx Scale
|
|
Physical Exam
|
|
General
• • •
|
General Abnormal
|
Head: Normal
• • •
|
Head: Abnormal
|
Eyes: Normal
• • •
|
Eyes Abnormal
|
If Visual Acuity Right
/
|
If Visual Acuity Left
/
|
If Visual Acuity Both Eyes
/
|
|
Ears: Normal
• • •
|
Ears Abnormal
|
Nose Normal
• • •
|
Nose Abnormal
|
Mouth: Normal
• • •
|
Mouth: Abnormal
|
Neck: Normal
• • •
|
Neck Abnormal
|
Chest: Normal
• • •
|
Chest Abnormal
|
Heart: Normal
• • •
|
Heart Abnormal
|
Abdomen: Normal
• • •
|
Abdomen Abnormal
|
Extremities: Normal
• • •
|
Extremities: Abnormal
|
Genital: Normal
• • •
|
Genital Abnormal
|
|
Tanner stage
|
Neurological: Normal
• • •
|
Neurological: Abnormal
|
Skin: Normal
• • •
|
Skin Abnormal
|
Denver Developmental screening
|
|
ASSESSMENT
|
|
ASSESSMENT: Dx:
• • •
|
Other specify
|
Plan
|
|
PLAN
• • •
|
Hearing screen
|
Hemoglobin test
|
Lead test
|
Return to clinic
|
Diet Plan:
|
Supplement/Herb Plan:
|
Rx:
|
Home care
|
Referral
|
Labs
|
Imaging
|
Other Plan
|
|