Interim History since last well child visit:

Concerns to discuss today:

OLD CARTS, present history in logical, chronological order

Review Past Medical History/Family Medical History (PMH/FMH):

Include appropriate information, including dates of hospitalizations/surgeries if possible, ages/illnesses of relatives

Medications:

Include names, dosages, and frequencies of prescription, over-the-counter, and alternative therapies

Allergies:

Include drug, food, and environmental allergies and patient's reaction

Social History:

Include who lives at home, who cares for the baby/daycare, smoke exposure, pets

Nutritional Assessment:

Breastfeeding ___min every ___hours.  

Mother's assessment of milk production:_____________

Formula: ___oz every ___hr

Other foods

Vitamins (Fluoride, Iron and Vitamin D)

Wet diapers per day

Stools per day

Parent concerns regarding nutrition or output

Mental Health Assessment/Ages and Stages Questionnaire:

Include infant crying (Colic), Sleep, family stress, parenting needs, Child abuse risk

Developmental Assessment/Ages and Stages Questionnaire:

List milestones achieved: gross motor/fine motor/language/personal-social

Review of Systems:
Physical Exam:

Vital signs

Include Weight_____,______(%), Length_____,______(%), Head circumference _____,______(%),
Weight for length

_____,______(%)

Temperature_______, Pulse_____,Respiratory Rate________, Blood Pressure (if applicable)____

General appearance

Head/Fontanelles

Eyes
Ears

Nose

Mouth and teeth
Oropharynx
Neck/nodes

Oropharynx

Neck/Nodes

Respiratory

Cardiovascular

Abdominal

Genitalia

Musculoskeletal/hips
Neuro/reflexes

Skin

Other

Screening:

Vision, Hearing, Hemoglobin, Lead questionnaire,Tuberculosis questionnaire, Dental screening/varnish 

Health Education/Anticipatory Guidance :

Nutrition: Formula/Breast, advancing diet, avoid honey, Women Infants and Children (WIC), growth charts

Safety: bath, hot water, smoke detectors, Car seats, childproofing, ingestiones, choking, Walkers, falls, sleep position, firearms

Health Promotion: immunizations, Tobacco exposure, Med. Resource Use, Minor acute illness, limit screen time, monitor screen content

Family: siblings, address concerns

Immunizations indicated today:

Labs (hemoglobin/lead/other)/procedures (dental varnish) indicated today:

Based on screening and Texas Health Steps recommendations

Next Well Check :