newborn visit - tennessee's voice for children & · pdf file ·...
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Physical Exam Undressed: o yes o noB/P if indicated _________ / ________ RA _/_ LA _/_ RL _/_ LL _/_
Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottledWet Diapers Per Day _________________Strong stream (if Male)? o Yes o NoStools per day ______________________WIC o Yes o No
Problems Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoExcessive crying o Yes o No______________________________________________________________________________________________________Family History _____________________Social History ______________________Hearing Risk AssessmentResponds to sounds o Yes o NoNewborn hearing screen:o Passed o Repeat scheduled ________
Vision Risk AssessmentLooks at parent’s face o Yes o No
Newborn Metabolic/HemoglobinopathyScreening o Normal o Repeat o Pending
Critical Congenital Heart Disease o Normal o Repeat o Pending
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Delivery Historyo Discharge Date _____o Hospitalo Gestational Age _____o SVD or C/So Membranes ruptured ___ hourso GBS: + -o Maternal labs ____o Baby blood type ___ Maternal blood type ___o HGB given: yes no o Birth weight __________________ o Discharge weight __________________o Complications __________________
Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Safe sleep/sleep on backo Crib safety, no blankets, 2-inch slatso Firm well fitting crib mattresso Never shake the baby
Healtho If bottle fed feedings 26 – 32 oz per dayo Sponge batheo Cord, circumcision careo Bowel movementso Fever > 100.4 o Discuss breastfeeding o No solids until 6 months o Discuss Well visit schedule o No Honey
Social/Behavioralo Parent/Child interactiono Sleepo Cuddle, talk, rocko Support for mothero Who makes up family
Impressiono Well Newborno Premature Infanto Jaundiceo ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo Hep B #1 (if indicated)o V.I.S./Counseling o Influenza/TdaP for caregiverso Vitamin D if breastfed 400 IU/Do Lactation consulto RTC at 1 month __________________o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlUmbilical Cord --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl Circ. ---------- o nl o abnl
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
Newborn Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
Physical Exam Undressed: o yes o noB/P if indicated _________ / ________ RA _/_ LA _/_ RL _/_ LL _/_
Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottledWet Diapers Per Day _________________Strong stream (if Male)? o Yes o NoStools per day ______________________WIC o Yes o No
Problems Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoExcessive crying o Yes o No______________________________________________________________________________________________________Family History _____________________Social History ______________________Hearing Risk AssessmentResponds to sounds o Yes o NoNewborn hearing screen:o Passed o Repeat scheduled ________
Vision Risk AssessmentLooks at parent’s face o Yes o No
Newborn Metabolic/HemoglobinopathyScreening o Normal o Repeat o Pending
Critical Congenital Heart Disease o Normal o Repeat o Pending
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Delivery Historyo Discharge Date _____o Hospitalo Gestational Age _____o SVD or C/So Membranes ruptured ___ hourso GBS: + -o Maternal labs ____o Baby blood type ___ Maternal blood type ___o HGB given: yes no o Birth weight __________________ o Discharge weight __________________o Complications __________________
Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Safe sleep/sleep on backo Crib safety, no blankets, 2-inch slatso Firm well fitting crib mattresso Never shake the baby
Healtho If bottle fed feedings 26 – 32 oz per dayo Sponge batheo Cord, circumcision careo Bowel movementso Fever > 100.4 o Discuss breastfeeding o No solids until 6 months o Discuss Well visit schedule o No Honey
Social/Behavioralo Parent/Child interactiono Sleepo Cuddle, talk, rocko Support for mothero Who makes up family
Impressiono Well Newborno Premature Infanto Jaundiceo ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo Hep B #1 (if indicated)o V.I.S./Counseling o Influenza/TdaP for caregiverso Vitamin D if breastfed 400 IU/Do Lactation consulto RTC at 1 month __________________o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlUmbilical Cord --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl Circ. ---------- o nl o abnl
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
3 to 5 Day Visit
B/P if indicated _________ / ________ RA _/_ LA _/_ RL _/_ LL _/_
Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottledWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoStuffy nose o Yes o NoColic o Yes o No______________________________________________________________________________________________________Hearing Risk Assessment
Responds to sounds o Yes o NoNewborn hearing screen:o Passed o Repeat scheduled ________
Vision Risk AssessmentLooks at parent’s face o Yes o NoFollows with eyes o Yes o No
Newborn Metabolic/HemoglobinopathyScreening o Normal o Repeat o Pending
TB Risk Assessment* — +
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Maternal Postpartum Depression Screen — +
Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Safe sleep/sleep on backo Crib safety: 2-inch slats, no objects in bedo Never shake the baby
Healtho If bottle fed, 26 – 32 oz per dayo If breast fed, nurses 8-10 times/dayo Delay solidso Bowel movementso Strong urinary stream if maleo Fever o No Honey
Social/Behavioralo Tempermento Sleepo Talk to babyo Support for mother
Impressiono Well Newborno Normal Growtho Normal Developmento ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo Influenza/TdaP for caregivers o Hep Bo V.I.S./Counselingo Vitamin D if breast fed 400 IU/Do One month Handout sheet o PPD if at risko RTC at 2 monthso Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlUmbilical Cord --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl Circ. ---------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
One Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
B/P if indicated _________ / ________ RA _/_ LA _/_ RL _/_ LL _/_
Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottledWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _________________________________________________________
Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoStuffy nose o Yes o NoColic o Yes o NoDiaper rash o Yes o No
Hearing Risk AssessmentResponds to sounds o Yes o NoSmiles and laughs o Yes o NoNewborn hearing screen:o Passed o Repeat scheduled o Not done
Vision Risk AssessmentLooks at parent’s face o Yes o NoFollows with eyes o Yes o No
Newborn Metabolic/Hemoglobinopathy Screening:o Normal o Repeat o Pending
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Maternal Postpartum Depression Screen — +
Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Safe sleep/sleep on backo Crib safetyo Rolling over, prevent falls
Healtho If bottle fed, 26 – 32 oz per dayo If breast fed, nurses 8-10 times/dayo Delay solidso Bowel movementso Strong urinary stream if maleo Fever o No Honey
Social/Behavioralo Tempermento Sleepo Talk to babyo Support for mother
Impressiono Well Newborno Normal Growtho Normal Developmento ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo Influenza/TdaP for caregivers o Hep B, Rotavirus, DTaP, Hib, PCV-13, IPVo V.I.S./Counselingo Acetaminophen__________mg. q. 4-6 hrs.o Vitamin D if breast fed 400 IU/Do Two month Handout sheeto RTC at 4 months o Parent declination of treatment ______o Referrals _______________________o ________________________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
Two Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
B/P if high risk: _________ / ________
Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottledWIC o Yes o No
Anemia Risk Assessment — + Preterm ___ Low birth weight ___ Breast feeding ____ Low iron formula ____
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoDiaper rash o Yes o No
Speech/Hearing Risk AssessmentResponds to sounds o Yes o NoBabbles and coos o Yes o No
Vision Risk AssessmentLooks at parent’s face o Yes o NoFollows with eyes o Yes o No
Newborn Metabolic/HemoglobinopathyScreening o Normal o Repeat o Pending
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Maternal Postpartum Depression Screen — +
Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Roll over, fall preventiono Bath safety o Safe sleep/sleep on backo No baby walkerso Child proof home
Healtho If bottle fed, 26 – 32 oz per dayo If breast fed, nurses 8-10 times/dayo Introduce solidso Avoid honeyo Teething
Social/Behavioralo Tempermento Sleep, bedtime routineo Talk, read to babyo Family support
Impressiono Well Babyo Normal Growtho Normal Developmento ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo Hep B, Rotavirus, DTaP, Hib, PCV-13, IPVo V.I.S./Counselingo Acetaminophen__________mg. q. 4-6 hrs.o Vitamin D if breast fed 400 IU/Do Four month Handout sheeto RTC at 6 months o Iron supplement: 2 mg/kg/d if preterm or low birth weighto1 mg/kg/d if low iron formula or breastfed o Hgb if at risko Parent declination of treatment ______o Referrals _______________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
Four Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
B/P if high risk: _________ / ________
Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoCereal/baby food o Yes o NoWater: o city o well o spring o bottled o fluoridatedWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Constipation o Yes o NoSleep o Yes o NoDiaper rash o Yes o No
Speech/Hearing Risk AssessmentResponds to sounds o Yes o NoJabbers and laughs o Yes o No
Vision Risk AssessmentLooks at parent’s face o Yes o NoFollows with eyes o Yes o No
Dental Risk Assessment* — + TB Risk Assessment* — + Lead Risk Assessment* — +
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso Always supervise batho Rolling over, fall prevention o Safe sleep/sleep on backo No baby walkerso Child proof home o Sunburn prevention
Healtho Continue formula or breast milko Introduce cereal, vegetables, fruits, meatso Introduce cupo Avoid honeyo Teething/clean teeth o Physical activity o No bottle in bed or bottle propping
Social/Behavioralo Tempermento Sleep, bedtime routineo Talk, read to babyo Family supporto No TV/media
Impressiono Well Babyo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Hep B, Rotavirus, DTaP, Hib, PCV-13, IPVo Influenza vaccine o V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrs.o Vitamin D if breast fed 400 IU/Do Six month Handout sheet o Hgb if at risko Lead level if at risko RTC at 9 months o Poison Control o Refer to dental home if risk assessment + o Fluoride Varnish o Iron supplement: 2 mg/kg/d if preterm or low birth weight; 1 mg/kg/d if low iron formula or breastfedo Parent declination of treatment ______ o Referrals _______________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
Six Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
B/P if high risk: _________ / ________
Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottled o fluoridatedBaby food__________servings per day Table food o Yes o No WIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Speech/Hearing Risk AssessmentResponds to sounds o Yes o NoImitates speech o Yes o No
Vision Risk AssessmentNotices small objects o Yes o No
Dental Risk Assessment* — + Lead Risk Assessment* — +
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Developmental Screeningo Normal o Abnormal
Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso Always supervise batho Fall prevention/gateso Poison Control numbero Child proof home o Safe sleep/sleep on back o Sunburn preventionHealtho Continue formula or breast milko Introduce table, finger foodo Choking preventiono Introduce cup, weaningo Avoid honey o Physical activityo Teething/clean teeth o No bottle in bed or bottle proppingSocial/Behavioralo Exploring, set consistent limitso Sleep, bedtime routineo Talk, read to babyo Separation Anxiety o Family support o No TV/mediao Day care o Yes o No
Impressiono Well Babyo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Hep B, DTaP, Hib, PCV-13, IPVo Influenza vaccine o V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrs.o Vitamin D if breast fed 400 IU/Do Dental referral (if at risk) o Fluoride Varnish o Lead level if at risk o Nine month Handout sheeto RTC at 12 months o Iron supplement: 2 mg/kg/d if preterm or low birth weight; 1 mg/kg/d if low iron formula or breastfedo Parent declination of treatment ______ o Referrals _______________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
Nine Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
B/P if high risk: _________ / ________
NutritionWhole milk o Yes o NoWeaned from bottle o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Speech/Hearing Risk AssessmentHears well o Yes o NoSays 2-4 words o Yes o No
Vision Risk AssessmentNotices small objects o Yes o No
Photorefractive Screen — + Dental Risk Assessment* — + TB Risk Assessment* — +
Lead Risk Assessment* — +
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Safetyo Car Seat, facing backward o Smoke detectors in homeo Hot water < 120 degreeso Water safety, supervise batho Close supervisiono Child proof home o Safe sleep/sleep on backo Poison Control Number o Sunburn prevention
Healtho Weaningo Introduce whole milk from cupo Limit juice, milk intakeo Changes in appetiteo Introduce table, finger foods o Choking prevention o Physical activity o Teething/clean teeth
Social/Behavioralo Set consistent limits, disciplineo Praise good behavioro Sleep, bedtime routineo Talk, read to childo Family o No TV
Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Hep B, Hib, PCV-13, IPV, MMR, Varicella, Hep Ao Influenza vaccineo V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrs.o Vitamin drops with irono Dental referral o Fluoride Varnish o PPD if at risko 12 month Handout sheeto RTC at 15 months o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________Lab Test Lead level__________________________________ (Required by TennCare)Hgb _____________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
12 Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
B/P if high risk __________ / ________
NutritionWhole milk o Yes o NoWeaned from bottle o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Speech/Hearing Risk AssessmentHears well o Yes o NoSays 3-6 words o Yes o No
Vision Risk AssessmentNotices small objects o Yes o No
Anemia Risk Assessment* — +Preterm ___ Low birth weight ___ Breast feeding ____ Low iron formula ____
Lead Risk Assessment* — +
Developmental Surveillanceo Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Safetyo Car Seat, facing backward until age 2 or > weight and height allowed by mfgo Smoke detectors in homeo No smoking in homeo Hot water < 120 degreeso Water safety, supervise bath
Safety (continued)o Close supervisiono Child proof homeo Poison Control Number o Sunburn prevention
Healtho Weaningo Whole milk until age 2o Limit juice, milk intakeo Picky appetites, self feedingo Offer varitety of foods o Choking prevention o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day o d/c pacifier/bottle o Physical activity o Brushing teeth
Social/Behavioralo Set consistent limits, disciplineo Praise good behavioro Discourage hitting, biting and other aggressive behavioro Sleep, bedtime routineo Talk, read to childo Family o No TV
Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Hep B, DTaP, Hib, PCV-13, IPV, MMR, Varicella, Hep Ao Influenza vaccineo V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrs.o Fluoride Varnisho Vitamin drops with irono 15 month Handout sheeto RTC at 18 months o Parent declination of treatment ______ o Referrals _______________________o ________________________________Lab Test Hgb ______________________________ (If not done at 12 months) Lead level _________________________ (If TennCare and not done at 12 months)_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
15 Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
B/P if high risk __________ / ________
NutritionWhole milk o Yes o NoWeaned from bottle o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Speech/Hearing Risk AssessmentHears well o Yes o NoSays 15-20 words o Yes o No
Vision Risk AssessmentNotices small objects o Yes o No
Dental Risk Assessment* — + Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____
Lead Risk Assessment* — +
Developmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Developmental Screening* o Normal o Abnormal Autism Screening* o Normal o Abnormal
Safetyo Car Seat, facing backward until age 2 or > weight and height allowed by mfgo Smoke detectors in homeo No smoking in homeo Hot water < 120 degrees
Safety (continued)o Water safety, supervise batho Close supervisiono Child proof homeo Poison Control Number o Sunburn prevention
Healtho Weaningo Whole milk until age 2o Limit juice, milk intakeo Picky appetites, self feedingo Offer varitety of foods o Choking prevention o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day o Physical activity o Brushing teeth
Social/Behavioralo Set consistent limits, disciplineo Praise good behavioro Time out, tantrumso Talk, read to childo Family o Imitative/parallel playo No TV
Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo Hep B, MMR, Varicella, Hep A, DTaP, Hib, PCV-13, IPVo Influenza vaccineo V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrso Vitamin drops with iron o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risko 18 month Handout sheeto RTC at 2 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
18 Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC
B/P: _________ / ________ (meaningful use or if indicated)
NutritionWeaned from bottle o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________ bread __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Dyslipidemia Risk Assessment — +FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o No BP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____
Speech/Hearing Risk AssessmentHears well o Yes o No2-3 word sentences o Yes o No
Vision Risk AssessmentSees distant objects well? o Yes o No
Photorefractive Screen — + Dental Risk Assessment* — +Anemia Risk Assessment* — + poverty ___ poor diet ____ chronic illness _____ TB Risk Assessment* — + Lead Risk Assessment* — +Developmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Developmental Screening* o Normal o Abnormal Autism Screening* o Normal o Abnormal
Safetyo Car Seat, facing backward until age 2 or > weight and height allowed by mfg o Use bike helmeto Smoke detectors in homeo No smoking in homeo Hot water < 120 degreeso Water safety, supervise batho Child proof home, supervisiono Poison Control Number o Firearm safety o Sunburn prevention
Healtho Low fat milk from cupo Limit juice, milk intakeo Picky appetites, self feedingo Choking prevention o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day o Physical activity o Brushing teethSocial/Behavioral
o Set limits, time outo Praise good behavioro TV/Media < 2 hrs/dayo Read to child o Toilet trainingo Sleep, bedtime routineo Family
Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo Hep B, Hep A, DTaP, IPVo Influenza vaccineo V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrso Vitamin drops with iron o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risko 2 year Handout sheeto RTC at 2 1/2 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________Lab Test Lead Level _________________________(Required by Tenncare at 12 and 24 months.)
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________
o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
24 Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height ______ in. BMI _____ %tile Head circ. _____cm Temp. _____AX Oral
B/P: _________ / ________ (meaningful use or if indicated)
NutritionWeaned from bottle o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________ bread __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — +FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o No BP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____
Speech/Hearing Risk AssessmentHears well o Yes o No2-3 word sentences o Yes o No
Vision Risk AssessmentSees distant objects well? o Yes o No
Dental Risk Assessment* — + Anemia Risk Assessment* — + Poverty ___ Poor Diet ____ Chronic Illness _____
Developmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Developmental Screening* o Normal o AbnormalSafetyo car seat in back forward facing o Use bike helmeto Smoke detectors in homeo No smoking in homeo Hot water < 120 degrees
Safety (continued)
o Water safety, supervise batho Child proof home, supervisiono Poison Control Number o Firearm safety o Sunburn prevention
Healtho Low fat milk from cupo Limit juice, milk intakeo Picky appetites, self feedingo Choking prevention o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day o Physical activity o Brushing teeth
Social/Behavioralo Set limits, time outo Praise good behavioro TV/Media - < 2 hrs/dayo Read to child o Toilet trainingo Sleep, bedtime routineo Familyo Day care, pre-school o Yes o No
Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo Hep Ao Influenza vaccineo V.I.S./Counselingo Vitamin drops with iron o Dental referral o Fluoride Varnish o Hgb if at risko 2 1/2 year Handout sheeto RTC at 3 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
30 Month Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height _________in. BMI ________ %tile Temp. _______AX Oral
B/P: ________ / ________
NutritionLow fat milk, cup only o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________ bread __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________
Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o No BP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____Speech/Hearing Risk AssessmentHears well o Yes o NoTalks well o Yes o NoEasy to understand? o Yes o NoVision Vision screening test:L near 20/ ____________ far 20/ ___________ R near 20/ ____________ far 20/ ___________Photorefractive Screen — + Anemia Risk Assessment* — + poverty ___ poor diet ____ chronic illness _____ Lead Risk Assessment* — + Dental Risk Assessment — + TB Risk Assessment* — +Developmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Safetyo Car seat in back forward facing o Bike helmeto Smoke detectors in homeo No smoking in homeo Water safety, supervise bath o Outdoor safety, supervisiono Poison Control Number o Firearm safety o Sunburn prevention
Healtho Low fat milk from cupo Limit juice, milk intakeo Picky appetites, self feedingo Low fat foods, healthy snacks o Brush teeth, see dentist o Encourage Active Play o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day
Social/Behavioralo Discipline, time outo Praise good behavioro TV limits o Read to childo Self help skills o Toilet trainingo Family
Safety (continued)o Friends and playmates o Curiosity about sexo Day care, pre-school o Yes o NoImpressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Influenza vaccineo V.I.S./Counselingo Chewable vitamins with iron o Cholesterol –Fasting Lipid Profile (if at risk)_____ o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risk o PPD if at risko 3 year Handout sheeto RTC at 4 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
3 Year Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height _________in. BMI ________ %tile Temp. _______AX Oral
B/P: ________ / ________
NutritionAppetite o good o variable o pickyWater: o city o well o spring o bottled o fluoridatedWIC o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o No BP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____
Speech/Hearing Risk Assessment Hearing screening test o Pass o Abnormal o Unable to testVision Vision screening test:L near 20/ ____________ far 20/ ___________ R near 20/ ____________ far 20/ ___________Photorefractive Screen — + Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____ Lead Risk Assessment* — + TB Risk Assessment* — +
Developmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Safetyo Booster seat – rear seat – 4-8 years or < 4’9” tall o Never put child in front seat if you have air bagso Bike helmet
Safety (continued)
o Smoke detectors in homeo No smoking in homeo Water safety, swimming lessons o Outdoor safety, supervision o Firearm safety o Sunburn prevention
Healtho Low fat milk o Limit Juiceo Encourage fruits and vegetableso Brush teeth, see dentist o Encourage active play o < 20-30% of calories from dietary fat o < 10% of calories from saturated fat o < 300 mg of cholesterol per day
Social/Behavioralo Discipline, time outo Praise good behavioro Read to child o TV/Media – limit <2 hrs/day, monitor contento Dresses self, helps at home o Familyo Friends and playmates o Curiosity about sexo Day care, pre-school o Yes o No
Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________
Plan/Referralso Immunizations current? o Yes o Noo DTaP, IPV (4th dose on/after 4th bday), MMR, Varicella, Hep A o Influenza vaccineo V.I.S./Counselingo Chewable vitamins with iron o Cholesterol –Fasting Lipid Profile (if at risk)_____ o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risk o PPD if at risko 4 year Handout sheeto RTC at 5 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________
_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
4 Year Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height _________in. BMI ________ %tile Temp. _______AX Oral
B/P: ________ / ________
NutritionAppetite o good o variable o pickyWater: o city o well o spring o bottled o fluoridatedWIC o Yes o No
Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________
Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________
Speech/Hearing Risk AssessmentHearing screening test o Pass o Abnormal o Unable to test
Vision Vision screening test:L near 20/ __________ far 20/ ____________ R near 20/ __________ far 20/ ____________ photorefractive screen — +
Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____ Lead Risk Assessment* — + TB Risk Assessment* — +
Developmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
Safetyo Booster seat – rear seat – 4-8 years or < 4’9” tallo Bike helmet, street safetyo Smoke detectors in homeo No smoking in homeo Water safety, swimming lessons o Outdoor safety, supervision o Firearm safety o Sunburn prevention
Healtho Low fat milko Encourage fruits and vegetableso Brush teeth, see dentist o Encourage active play o < 20-30% of calories from dietary fat o < 10% of calories from saturated fat o < 300 mg of cholesterol per day
Social/Behavioralo Give choices o Encourage independenceo Praise good behavioro TV limits, read to childo Help child handle angry feelings and resolve conflicts with others o Family relationshipso Friends and playmates o Questions about sexo Pre-school, school readiness
Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo DTaP, IPV (4th dose on/after 4th bday), MMR, *Varicella (2 doses or hx of dz), Hep A o Influenza vaccineo V.I.S./Counselingo Chewable vitamins with iron o If BMI >85%, follow-up plan o Cholesterol –Fasting Lipid Profile (if at risk)_____ o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risk o PPD if at risko 5 year Handout sheeto RTC at ______ years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------ o nl o abnlHead ---------------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form * Required for Kindergarten entry
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
5 Year Visit/Kindergarten Check-up
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height _________in. BMI ________ %tile Temp. _______AX Oral
B/P: ________ / ________NutritionLow fat milk? o Yes o NoVariety of fruits, vegetables? o Yes o No Eats breakfast? o Yes o NoEats supper with family? o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o NoBP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____ Dyslypidemia Screen ____(Once between 9-11 years)Hearing Risk Assessment (7 and 9 yrs) — + Hearing screen (6, 8, 10 yrs) o Normal o AbnormalDate:______________________
Vision Risk Assessment (7 and 9 yrs) — +Vision screen (6, 8, 10 yrs) L near 20/ ______________ far 20/ ________ R near 20/ ______________ far 20/ ________ o Wears glasses, sees eye specialist
Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____ Dental Risk Assessment (age 6 years) — + Lead Risk Assessment* — + (through age 6) TB Risk Assessment* — +
Developmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
o Normal o AbnormalSchool Grade____________ Problems? o Yes o NoIf Yes, what? _______________________
Safetyo Buckle up! Ride in back seato Booster seat – rear seat – 4-8 years or < 4’9” tall
OR seat belt –rear seat over 8 years or > 4’9” tallo Bike helmet, street safetyo Smoke detectors in homeo No smoking in homeo Water safety, swimming lessonso Firearm safetyo Sunburn preventionHealtho Low fat milk and snackso Encourage fruits and vegetableso Brush teeth, see dentisto Adequate sleepo Encourage sports, active playo Sports form completedo < 20-30% of calories from dietary fato < 10% of calories from saturated fato < 300 mg of cholesterol per daySocial/Behavioralo School adjustment, performanceo Sports and hobbieso Limit TV, computer games <2 hrs/dayo Give choiceso Encourage independenceo Set limits, provide consequenceso Parent supervises peer activitieso Privacy, personal hygieneo Puberty changes and questions about sexo Family relationshipso Friends and Schoolo Social media, safety settingso Dealing with strangers
Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo DTaP/Td/Tdap, IPV (4th dose on/after
4th bday), MMR, *Varicella (2 dosesor hx of dz), HPV
o Influenza vaccineo V.I.S./Counselingo Cholesterol –Fasting Lipid Profile
(if at risk 2-8 yrs)_____o Cholesterol - Non-fasting Lipid Profile
or Fasting Lipid Profile (once between 9and 11 years)________
o Lead level if at risko PPD if at risko Dental referral at age 6o Hgb (if + menarche or high risk every
year)__________o If BMI >85%, follow-up plano RTC at ______ yearso Handoutso Parent declination of treatment ______o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------------ o nl o abnlHead ---------------------- o nl o abnlNeck ---------------------- o nl o abnlEyes ---------------------- o nl o abnlEars ---------------------- o nl o abnlNose ---------------------- o nl o abnlThroat/Mouth/Teeth -- o nl o abnlChest Breasts/Tanner Stage -- o nl o abnlLungs--------------------- o nl o abnlHeart --------------------- o nl o abnlAbdomen ---------------- o nl o abnlFemoral Pulses --------- o nl o abnlSpine --------------------- o nl o abnlExtremities -------------- o nl o abnlHips/Gait --------------- o nl o abnlSkin ---------------------- o nl o abnlNeuro --------------------- o nl o abnlGenitalia/Tanner Stage Female o Male o
Physical Exam Undressed: o yes o no
* see separate form * Required for Kindergarten entry
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
6 to 10 Year Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height _________in. BMI ________ %tile Temp. _______AX Oral
B/P: ________ / ________NutritionLow fat milk? o Yes o NoVariety of fruits, vegetables? o Yes o No Eats breakfast? o Yes o NoEats supper with family? o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o NoBP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____ Dyslypidemia Screen ____(Once between 9-11 years)Hearing Risk Assessment (11 - 15 years) — +Vision Risk Assessment (11, 13 and 14 years) — + Vision Screen (12 and 15 years) L near 20/ ______________ far 20/ ________R near 20/ ______________ far 20/ ________o Wears glasses, sees eye specialist
Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____ menorrhagia ____ Alcohol/Drug Screen (11-21 years) — + TB Risk Assessment — + STI/HIV Risk Assessment (11-21 years) Hx of sexual activity — + Hx of IV drug use — + Depression Screening* (11-21 years) o Normal o AbnormalDevelopmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
School Grade____________ Problems? o Yes o NoIf Yes, what? _______________________ __________________________________
Safetyo Buckle up!o Bike helmet, street safetyo Smoke detectors in homeo No smoking in homeo Swimming, water safetyo Firearm safetyo Sunburn preventionHealtho Low fat milk and snackso Healthy food choices, Ca intakeo Brush teeth, see dentisto < 20-30% of calories from dietary fato < 10% of calories from saturated fato < 300 mg of cholesterol per dayo Adequate sleepo Acneo Encourage sports, active playo Sports form attached o Yes o NoSocial/Behavioralo School adjustment, performanceo Sports and hobbieso Limit TV, computer gameso Give choiceso Encourage independenceo Set limits, provide consequenceso Managing stress, angero Say no to alcohol, drugs, tobaccoo Puberty changes and questions about sexo Periods (girls) LMP _______________o Family relationshipso Friends, boy/girl friendso Abstinence, birth control
Social/Behavioral (continued)o Social Mediao Sleep hygieneo + eating disorder screenImpressiono Well Child/Adolescento Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo *Tdap, MCV4, *Varicella (2 doses or hx
or dz), Hep B, HPV o Influenza vaccineo V.I.S./Counselingo RTC at ______ yearso Handoutso Cholesterol - Non-fasting Lipid Profile
or Fasting Lipid Profile (once between 9and 11 years)
o Cholesterol – Fasting Lipid Profile (12-16years) only if new risk factors in self or family
o Hgb (if + menarche or high risk everyyear)__________
o PPD if at risko STD screeningo Begin transition plano Parent declination of treatment ______o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------------ o nl o abnlHead ---------------------- o nl o abnlNeck ---------------------- o nl o abnlEyes ---------------------- o nl o abnlEars ---------------------- o nl o abnlNose ---------------------- o nl o abnlThroat/Mouth/Teeth -- o nl o abnlChest Breasts/Tanner Stage -- o nl o abnlLungs--------------------- o nl o abnlHeart --------------------- o nl o abnlAbdomen ---------------- o nl o abnlFemoral Pulses --------- o nl o abnlExtremities -------------- o nl o abnlGenitalia/Tanner Stage Female o Male o
Musculoskeletal ExamShoulder/arm ----------- o nl o abnlElbow/foremarm ------- o nl o abnlWrist/hand/fingers ---- o nl o abnlHips/thigh --------------- o nl o abnlKnee ---------------------- o nl o abnlLeg/ankle ---------------- o nl o abnlFoot/toes ----------------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form * Required for 7th Grade entry
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
11 to 15 Year Visit
Date _______________________ Form revised 06/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height _________in. BMI ________ %tile Temp. _______AX Oral
B/P: ________ / ________NutritionLow fat milk? o Yes o NoVariety of fruits, vegetables? o Yes o No Eats breakfast? o Yes o NoEats supper with family? o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M ____________o Yes _____________________________o NoFH CVD heart disease <65 F ____________o Yes _____________________________o NoFH cholesterol o Yes o NoBP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____ Dyslypidemia Screen ____(Once between 18-21 years)Hearing Risk Assessment (16 - 21 years) — +Vision Risk Assessment (16 - 21 years) — + o Wears glasses, sees eye specialistAnemia Risk Assessment* — + poverty ___ poor diet ____ chronic illness _____ menorrhagia ____ Alcohol/Drug Use — + Assessment*(11-21 years) Ethoh, drug or substance to get high — + TB Risk Assessment — + STI/HIV Risk Assessment (11-21 years) Hx of sexual activity — + Hx of IV drug use — + HIV Screen ____(Once between 16-18 years) Depression Screening* (11-21 years) o Normal o AbnormalDevelopmental Surveillance o Yes o No Concerns? _____________
Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________
School Grade____________ Problems? o Yes o NoIf Yes, what? _______________________ __________________________________
Safetyo Driving and automobile safetyo Bike helmet, safetyo Smoke detectors in homeo Swimming, water safetyo Firearm safetyo Sunburn prevention, tanning bedsHealtho Healthy food choices, Ca++ intakeo Concerns about weight, body imageo Periods (girls) LMP____________o < 20-30% of calories from dietary fato < 10% of calories from saturated fato < 300 mg of cholesterol per dayo Adequate sleepo Acneo Encourage sports, exerciseo Sports form attached o Yes o NoSocial/Behavioralo School adjustment, performanceo Plans for work/further educationo Tobacco useo Drug and alcohol useo Dealing with stress, angero Limit TV, computer time <2 hrs/dayo Friends and funo Boy or girl friends /dating safetyo Abstinence, birth controlo STDso Family relationships
Social/Behavioral (continued)o Social Mediao Sleep hygieneo Eating disorder screen — +Impressiono Well Adolescento Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Tdap, MCV4 Booster, Varicella, HPV, Hep Bo Influenza vaccineo V.I.S./Counselingo RTC at ______ yearso Handoutso Cholesterol – Non-fasting Lipid Profile if
at risk 16-17 years. Non-Fasting LipidProfile once between 18-21 years
o Hgb (if + menarche or high risk everyyear)__________
o Pap - 21 yearso STD screeningo HIV Screen (once between 16 and 18)o PPD if at risko Review transition plano Parent declination of treatment ______o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation
General ------------------ o nl o abnlHead ---------------------- o nl o abnlNeck ---------------------- o nl o abnlEyes ---------------------- o nl o abnlEars ---------------------- o nl o abnlNose ---------------------- o nl o abnlThroat/Mouth/Teeth -- o nl o abnlChest Breasts/Tanner Stage -- o nl o abnlLungs--------------------- o nl o abnlHeart --------------------- o nl o abnlAbdomen ---------------- o nl o abnlFemoral Pulses --------- o nl o abnlExtremities -------------- o nl o abnlGenitalia/Tanner Stage Female o Male o
Musculoskeletal ExamShoulder/arm ----------- o nl o abnlElbow/foremarm ------- o nl o abnlWrist/hand/fingers ---- o nl o abnlHips/thigh --------------- o nl o abnlKnee ---------------------- o nl o abnlLeg/ankle ---------------- o nl o abnlFoot/toes ----------------- o nl o abnl
Physical Exam Undressed: o yes o no
* see separate form
Note: Bright Futures recommends screenings through age 21. TennCare Kids provides coverage for children birth until age 20 and ends when a member turns age 21. Any recommendation that mentions “21 years” as an end-date is not a TennCare Kids covered service.
American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM
Tennessee Chapter
®
16 to 20 Year Visit
Date _______________________ Form revised 11/16
Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height _________in. BMI ________ %tile Temp. _______AX Oral