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