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NAME DOB

ID# Rm#

CC:

ID:

Source:

Referring MD:

HPI:

PMH:

Illnesses:

Surgery:

Meds:

Allergies:

Immunizations:

BHx: The pt was the _____ gm/lb product of a

_____ week gestation born to a ____ y.o. G____ P____

Ab____ M / S ______ female delivered by

________________ following an __________ pregnancy

w/ Apgars of ____ and ___.

Feeding:

Menstrual Hx:

Menarche: LMP: BCP:

Last Pap: Breast:

Developmental Hx:

•Gross Motor:

•Fine Motor:

•Language:

•Problem Solving:

Prenatal Hx:

FHx:

SHx:

Home Unit:

Employment:

Economic:

Tobacco

EtOH

Other

Activities

Diet

Sexual Hx:

Active: M W B # Partners:

Protection?Safety

Other

ROS:

Vision

Hearing

Smell

Taste

Run/Keep up w/others?

Chest Pain Belly PainDysuria

Easy bruising

Happy child?

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PE

•General: Well-appearing / Irritable but

consolable / Irritable and non-consolable / Toxic

•VS: T P RR BP

•Growth:

Wt = _______ ( %ile)

Ht = ________ ( %ile)

HC = _______ ( %ile)

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Neck:

Chest:

Cardiac:

Abdomen:

GU:

Back:

Ext:

Skin:

Neuro:

Mental status:

Motor: Tone

Bulk

Strength

Sens: Lt. touch

Pain

Proprioception

Vibration

DTR’s: Patellar

Ankle

Biceps

Cerebellum:

CN:

Primitive Reflexes:

Developmental Exam:

•Gross Motor:

•Fine Motor:

•Language:

•Problem Solving:

LABS

PROBLEM LIST:

1) _________________________________

A/

Diff Dx:

P/ 

2) _________________________________

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A/

Diff Dx:

P/ 

3) _________________________________

A/

Diff Dx:

P/ 

TO DO: